
Glass 
Book 



COPYRIGHT DEPOSIT 



THE 



PRINCIPLES AND PRACTICE 



roPYRlO^ 



SURGERY. IA 



u 



ILLUSTRATED BY 



THREE HUNDRED AND SIXTEEN ENGRAVINGS ON WOOD. 



BY 



WILLIAM PIRRIE, F.R.S.E., 

REGIUS PROFESSOR OF SURGERY IN THE MARISCHAL COLLEGE AND UNIVERSITY OF ABERDEEN: 
SURGEON TO THE ROYAL INFIRMARY, ETC., ETC. 



EDITED, WITH ADDITIONS, BY 

JOHN NEILL, M.D., 

/c — -' 

SURGEON TO THE PENNA. HOSPITAL, 
DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 




PHILADELPHIA: 
BLANCHARD AND LEA. 

1852. 






b\ 



?*« 



Entered, according to Act of Congress, in the year 1S52, 

BY BLANCHAB.D AND LEA, 

In the Clerk's Office of the District Court for the Eastern District of Pennsj'lvania. 



C. SHERMAN, P R I N T i 

19 St. James Street. 



TO 

THE STUDENTS OF SURGERY 

OF 

THE MARISCHAL COLLEGE AND UNIVERSITY OF ABERDEEN, 

IN GRATEFUL REMEMBRANCE OF 

THE PLEASURE HE HAS UNIFORMLY EXPERIENCED 

IN HIS CONNEXION WITH THEM, 

AND IN TESTIMONY OF 

THE LIVELY INTEREST HE FEELS IN THEIR 

PROFESSIONAL PROGRESS, 

THIS WORK IS DEDICATED BY 

THE AUTHOR. 



PREFACE TO THE ENGLISH EDITION. 



This work is not put before the public with the design of placing it 
in competition with any of the valuable treatises on the same subject 
already existing, but in compliance with a wish repeatedly expressed, 
on the part of the Students of Surgery at this University, to be furnished 
with a Compendium of my Lectures. 

For their use the work has been prepared ; and while I would venture 
to hope that others may find it not unserviceable, yet, if those, for 
whose especial use it is intended, derive benefit, my chief object will be 
obtained. 

It has been my endeavour to combine simplicity of arrangement, and 
conciseness and clearness of description, with the elucidation of sound 
principles and practice. How far that endeavour has been successful, 
I must leave my readers to determine. 

The wood-engravings are taken from drawings, the greater proportion 
of which are original delineations of preparations in my own Museum ; 
others are of patients who were under my care while the work was 
in progress ; and the rest are from authorities which are duly acknow- 
ledged. 

To Dr. Westmacott of London, I am indebted for his drawing, from 
sketches furnished by Mr. Cleland of this place, the greater part of the 
original illustrations, as well as for directing the artist in the process of 
engraving. The remainder of these will fully sustain the reputation of 



XXII PREFACE. 

Mr. Bagg. To Dr. Bennett I owe acknowledgments for the use of 
many wood-cuts, illustrative of the inflammatory process, and of the 
microscopic character of Tumours. My warmest thanks are due to my 
Publisher, for permission to use the blocks belonging to Mr. Liston's 
" Practical Surgery," with beautiful and instructive engravings from 
which many pages' of this work are adorned. 

238 Union Street, West Aberdeen, 
February 7th, 1852. 



EDITOR'S PREFACE, 



The duty which has been assigned the Editor, of bringing another 
Surgical work before the profession has been cheerfully undertaken, from 
his conviction of the high character and utility of the present volume. It is 
true, that comprehensive cyclopaedias and manuals, and instructive trea- 
tises on special surgical subjects, as well as beautiful illustrations of sur- 
gical anatomy and operative surgery, have been issued from the press in 
great profusion; but the want of a suitable text-book on surgery has 
been constantly felt by those who are called upon to recommend to 
students a guide to their surgical studies, and who desire to place in the 
hands of their pupils the elements of sound principles, combined with 
safe practice. 

This desideratum has been admirably supplied by Professor Pirrie, 
who has introduced recent views of pathology, and whose experience, both 
as a teacher and practitioner, has enabled him to give force and weight 
to his practical deductions ; and we therefore venture to say, that no work 
has been offered to the medical public, which has so many claims to re- 
commend it to the student of medicine. 

Difficult as it is to limit the amount of matter that should be included in 
a work of this kind, at the same time, it is equally important that it does 
not encroach upon the province of a dictionary, or of a work upon Minor 
Surgery. If every topic had been introduced, it would have exceeded its 



XXIV EDITOE S PEEFACE. 

appropriate limits, and not fulfilled the precise object of its publication. 
The Editor has, therefore, added but few new articles, some of which are 
upon subjects that may render it more acceptable to the American Stu- 
dent, while the liberality of the publishers has enabled him to in- 
crease the number of the illustrations. 



817 Spruce Street, 
July, 1852. 



CONTENTS 



CHAPTER I. 



Inflammation and its Results, . 



PAGE 

33 



CHAPTER II. 



Erythema and Erysipelas, 



62 



Wounds, 



CHAPTER III. 



Burns, 



CHAPTER IV. 



105 



Fractures, . 



CHAPTER V. 



126 



Injuries of the Head, 



CHAPTER VI. 



202 



Dislocations, 



CHAPTER VII. 



228 



CHAPTER VIII. 

Affections of the Osseous System, 



285 



XXVI CONTENTS. 



CHAPTER IX. 

PAGE 

Diseases or Joints, ........ 324 



CHAPTER X. 

Curvatures of the Spine, . . . . . . . 359 

CHAPTER XL 
Talipes, ........ . . 382 

CHAPTER XII. 

Affections of the Arteries and Veins, ...... 400 

CHAPTER XIII. 
Hernia, .......... 450 

CHAPTER XIV. 
Wounds of Abdomen, ........ 507 

CHAPTER XV. 

Calculous Disorders, . . . . . . . .514 

CHAPTER XVI. 

Affections of the Testicle, . , . ... . . 561 

CHAPTER XVII. 
Affections of Genito-Urinary Organs, ..... 578 

CHAPTER XVIII. 
Amputations and Resections, ....... G08 

CHAPTER XIX. 
Deligation of Arteries, ......*. G34 



CONTENTS. XXV11 



CHAPTER XX. 

PAGE 

Affections of Rectum, ........ 649 



CHAPTER XXI. 

Affections of the Eye and its Appendages, ..... 657 

CHAPTER XXII. 
Affections of Nose, ........ 710 

CHAPTER XXIII. 
Affections of Mouth, Throat, and Windpipe, ..... 720 

CHAPTER XXIV. 
Tumours, .......... 753 



CHAPTER XXV. 

Affections of Breast, 



LIST OF ILLUSTRATIONS. 



9. 
10. 
11. 

12. 
13. 
14. 
15. 
16. 
17. 
18. 
19, 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
35. 
36, 
38. 
39. 
40. 
41. 
42. 
43. 
44, 
46. 
47. 
48. 
49- 
55. 



Example of Intervascular Deposit, 
Web in the Foot of a Frog, inflamed, 
Example of Exudation, 
Changes in Blood Globules, 
Nuclei developing themselves into Fibres, 
Cells developing themselves into Fibres, 
Pus Corpuscles, 

Ulcer Cicatrizing in the Middle, 
Healthy Ulcer, 
Weak Ulcer, 
Indolent Ulcer, 
Inflamed Ulcer, . 
Phagedsenic Ulcer, 
Gangrenous Ulcer, 
Interrupted Suture, 
Hare-lip Suture, 

Fracture of the Radius at the Wrist, 
Fracture of the Radius and Ulna, 
20. Bond's Splint, 
Fracture of the Olecranon, 
Fracture of the Neck of the Humerus, 
Fracture of the Body of the Scapula, 
Dressing for Fracture of Neck of Scapula, . 
Fox's Apparatus for Fractured Clavicle, 
Intra-capsular Fracture of the Neck of the Thigh Bone, 
Deformity of the Neck of the Thigh Bone, 

Fracture of the Neck of the Femur without Inversion or Eversion, 
Extra-capsular Fracture of the Femur, 
Fracture through the Trochanter Major, 
Intra-capsular Fracture of the Femur, 
Liston's Modification of Desault's Splints, 
Physick's Modification of Desault's Splints, . '. 

Gibson's Modification of Hagedorn's Splints, 
Fracture of both Condyles of Femur, 
37. Fracture of the Patella, 
Displacement of the Patella, 
Fracture of both Bones of the Leg, . 
Liston's Cradle, . 
Liston's Cradle Applied, 
Fracture Box, . . 

Dupuytren's Splint for the Fibula, 
45. Fracture of the Ribs, 
Fracture at the Base of the Skull, 
Simple Fissure of the Skull, 
Simple Fracture -with Depression, 
-54. Instruments for Trephining, 
Punctured Fracture of the Cranium, 



LIST OP ILLUSTRATIONS. 



XXIX 



56. Fracture of the Lower Jaw, 

57. Bandage for the Lower Jaw, 

58. Barton's Bandage for the Lower Jaw, 

59. 60. Dislocations of the Lower Jaw, . 

61. Dislocation downwards of the Shoulder Joint, . 

62. Dislocation downwards and forwards of the Humerus, 

63. 64. Reduction of the Humerus, 

65, 66. Dislocation forwards of the Humerus, 

67. Dislocation of the Humerus backwards, 

68. Dislocation of the Humerus upwards, 
69,70. Dislocation of the Elbow, 

71, 72. Dislocation forwards of the Radius, 

78. Clove Hitch, ..... 

74. Dislocation of the Femur upwards and backwards, 



To. 

70. 



79. 

80. 
81. 
82. 



Reduction of the Femur, 
Gilbert's Mode of Reduction, 
Dislocation into the Sciatic Notch, 
Reduction of Dislocation into the Sciatic Notch, 
Dislocation of Femur into the Foramen Ovale, 
Reduction of Dislocation of the Femur into the Foramen Ovale, 
Dislocation of Femur upon the Pubes, 
Reduction of Dislocation of Femur upon the Pubes, 
83, 84. Dislocation of the Tibia inwards, 

85. Dislocation of the Tibia outwards, 

86. Suppuration in Bone, .... 
87-89. Abscess in Bone, .... 
90, 91. Caries of the Cranium and Face, 

92. Necrosis of Femur, .... 

93. Reproduction of Tibia, .... 

94. Cloaca? of Femur, .... 

95. 96. Rickets affecting the Femur, 

97. Rickets affecting the Tibia, . 

98, 99. Rickets affecting the Humerus, 

100. Exostosis .of Femur, .... 

101. Osteosarcoma of Femur, 

102. Fimbriated Synovial Membrane, 
103-105. Diseased Articular Cartilage, 

106. Anchylosis of Hip Joint, . . . 

107. Perfect Anchylosis of Hip Joint, 

108. Section of Anchylosis of Hip Joint, 

109. Morbus Coxarius, showing Deformity, . 

110. Morbus Coxarius, showing changes in Acetabulum, 

111. 112. Morbus Coxarius, showing changes in the Head of the Femur 

113. Mutter's Splint for Anchylosis, 

114, 115. Curvatures of the Spine, 

116. Deformity in the Spine, 

117. Excurvation of Spine, 

118. 119. Lateral Curvature of Spine, 

120. Effects of Lateral Curvature, 

121. Posterior view of the same, . 

122. Talipes Equinus, 

123. Stromeyer's Apparatus applied, 

124. Little's Boot applied, 

125. Opposite View of the same, . 

126. Talipes Varus, . 



PAGE 

226 
227 
227 
238 
244 
247 

247, 248 

251, 252 
254 

. 256 
257 
261 
265 
267 
268 
269 
270 
271 
272 
273 
274 
275 
280 
282 
294 

294, 295 

301, 303 
309 
310 
314 
317 
317 
318 
322 
323 
336 

333, 339 
341 
341 
341 
351 
352 
352 
356 
362 
366 
371 

375, 376 
377 
377 
382 
386 
387 
387 
388 



XXX 



LIST OF ILLUSTRATIONS. 



FIG. 

127. Talipes Varus, before Operation, 

128. Appearance of the same a fortnight after Operation, 

129. Appearance six weeks after, 

130. Talipes Varus before Operation, 

131. The same after Operation, .... 

132. Talipes Valgus, ..... 

133. Talipes Calcaneus, ..... 

134. Steatomatous Degeneration of Arteries, 

135. Calcareous Deposition, . 

136. Aneurism of the Aorta, .... 

137. Aneurism of the Innominata, 

138. Aneurism of the Aorta, inducing Caries of the Vertebrae, 

139. Aneurism of the Aorta, producing Absorption of the Ribs, 

140. Back view of the same, .... 

141. Aneurism of the Brachial Artery, 

142. Aneurism filled with Coagulum, 

143. Hunter's Operation for Aneurism, 

144. Brasdor's Operation for Aneurism, 

145. Wardrop's Operation for Aneurism, . 

146. False Aneurism, ..... 

147. 148. Aneurism of Varix, .... 

149. Varicose Aneurism, .... 

150, 151. Dissection for Inguinal Hernia, 

152. Dissection, showing Deeper Parts, 

153. Dissection, for Inguinal Hernia on both sides, 

154. Hernial Sac, ..... 

155. Hernial Sac, accompanied by Varicocele, 

156. 157. Bistoury for Hernia, 

158. Direct Inguinal Hernia on both sides, 

159. Sac of a Direct Inguinal Hernia, 

160. Seat of Stricture in Hernia, 

161. A Scrotal Hernia, .... 

162. Congenital Scrotal Hernia, .... 

163. The Femoral Arch and Grimbernat's Ligament, . 

164. The Femoral Vessels of the left side, 

165. The Groin of the right side Dissected, . 

166. Certain Parts concerned in Inguinal Hernia, 

167. Strangulated Intestine and Stricture, . 

168. Posterior View of the same, 

169. Relations of the Diverticulum to the Intestine, . 
170-172. Trocar and Canula, . 

173. Microscopic view of Lithic Acicl, 

174. Microscopic view of Phosphates, 

175. Microscopic view of Oxalates, 

176. 177. Renal Calculi, ..... 

178. Section of Stone, showing Nucleus, 

179. Uric Calculus, ..... 

180. Section of Calculus, showing Lamina 1 , . 

181. Mulberry Calculus, ..... 

182. Section of Calculus, .... 

183. Hemp-seed Calculus, .... 

184. Phosphatic Calculus, .... 

185. Ammoniaco-Magnesian Calculus, 

186. Fusible Calculus, .... 

187. Section of same, ..... 



LIST OF ILLUSTRATIONS. 



XXXI 



FIG. 

188. Cystic Calculus, 

189. Section of same, . 

190. Encysted Calculus, . 
191-195. Instruments for Lithotomy, 

196. Position of Patient during Lithotomy, 

197. Anatomy of Parts in Lithotomy, 

198. Lateral View of the same, 

199. Lateral operation of Lithotomy, 

200. Probe-pointed Lithotomy Knife, 

201. Section of Prostate Gland in Lithotomy 
202-207. Instruments constituting the Apparatus Major 

208. Double-edged Gorget, 

209. Single-edged Gorget, 

210. Physick's Gorget, 

211. Dupuytren's Double Lithotome, 

212. Weiss's Lithotriptor, 

213. Jacobson's Lithotriptor, 

214. Operation of Lithotripsy, 

215. Trocar for Hydrocele, 

216. Operation for Hydrocele, 

217. Phymosis, .... 

218. Paraphymosis, 

219. Enlargement of Prostate Gland, 

220. Artery Forceps, . 

221. Reef Knot, . 
222-224. Amputation of Finger, 

225. Amputation of Metacarpal Bone, 

226. Appearance afterwards, 

227. Amputation of Thumb, 

228. Amputation of Forearm, 

229. 230. Amputation of Arm, . 
231, 232. Amputation at Shoulder Joint, 

233. Amputation of Great Toe, 

234. Hey's Amputation of the Foot, . 

235. Chopart's Amputation of the Foot, . 

236. Syme's Amputation at the Ankle. 

237. Amputation of the Leg, 

238. 239. Amputation of the Thigh, 

240. Amputation of the Hip-joint, 

241. Tumour of the Lower Jaw, 

242. Resection of the Lower Jaw, 

243. Portion removed, 

244. Deligation of Carotid Artery, 

245. Deligation of Subclavian, 

246. Deligation of Axillary, 

247. Deligation of the Humeral, 

248. Deligation of the Radial and Ulnar. . 

249. Deligation of the Radial, 

250. Deligation of the Common Iliac, 

251. Deligation of the Femoral, 

252. Deligation of the Anterior Tibial, 

253. Deligation of the Posterior Tibial, 

254. Operation for Fistula in Ano, 

255. Simple Conjunctivitis, . 

256. Pustular Conjunctivitis, 







PAGE 








533 






536 






539 






540 






540 






541 






542 






543 






544 






547 






552 






552 






554 






556 






557 






558 






559 






574 






578 






588 






583 






595 






609 






610 






611, 612 






613 






613 






614 






615 






616, 617 






618 






619 






620 






621 






623 






624 






626 






627 






632 






632 






633 






638 






639 






641 






641 






642 






642 






644 




, 


645 






646 






647 






650 




657 






658 



XXX11 



LIST OF ILLUSTRATIONS. 



FIG. 

257. Conical Cornea, .... 

258. Rheumatic Ophthalmia, .... 

259. Choroiditis, ..... 

260. Acute Iritis, ...... 

261. Spring Speculum, .... 

262. Small Tooth Forceps, .... 

263. Probe-pointed Scissors, : 

264. Small Iris Knife, ..... 

265. Hook for seizing the Rectus Muscle, 

266. Operation for Fistula Lachrymalis, 

267. Case of Lipoma of the Nose, . 

268. The same, after operation, .... 

269. Polypus of the Nose, • 

270. Speculum for the Nose, .... 

271. Forceps for Polypus, . • . 

272. Operation for Polypus, .... 

273. Operation for Plugging the Posterior Nares, 

274. Rhinoplastic Flap, .... 

275. Microscopic view of Cancer of the Cheek, 

276. Cancer of the Lip, . . . . 

277. Hare-lip, ..... 

278. Hare-lip Suture, ..... 

279. Double Hare-lip, . 

280. Operation of the same, .... 

281. Removal of the Tonsil, .... 

282. 283. Operation of Tracheotomy, 

284. Section of a Fibrous Tumour of the Uterus, 

285. Structure of a Fatty Tumour, 

286. Enchondroma, 

287. Ossification of Enchondromatous Tumours, 

288. Osseous Tumours of Innominatum, 

289. Back view of the same, .... 
290-292. Corpuscles from Tubercle, . 

293. Section of a Cancer of the Breast, . 

294. The same treated with Acetic Acid, 

295. Cancer-Cells, . . . 

296. The same, treated with Acetic Acid, 

297. Dense Fibrous Tissue infiltrated with Cancer-Cells, 

298. Cancer-Cells, ..... 

299. The same, after addition of Acetic Acid, 

300. Older Cancer-Cells, . . . 

301. Older Cancer-Cells, after addition of Acetic Acid, . 

302. Advanced Cancer-Cells, with Secondary Cells, 
303-305. Cancer-Cells, ..... 

306. Young Cancer-Cells, . . ■ * . 

307. Young Cancer-Cells, after addition of Acetic Acid, . 

308-311. Structure of Colloid Cancer, before and after the addition of Acetic 
312. Melanic Cancer of Cheek, :..... 
313-315. Microscopic Sections of the Nipple Tumour, 
316. Serocystic Tumour of the Breast, ..... 



708 
710 
711 
712 
713 
713 
715 
716 
717 
720 
722 
723 
724 
724 
724 
733 
736, 737 



Acid, 



THE 



PRINCIPLES AND PRACTICE OF SURGERY. 



CHAPTER I. 

INFLAMMATION. 

Definition. — Inflammatiom may be defined, — " a peculiar perversion 
of nutrition or of secretion," attended with various abnormal conditions 
of the blood and its vessels, the most essential of which is exudation in 
the affected part. 

To give greater clearness to the description of the phenomena of in- 
flammation, we shall, in the first instance, allude to those produced by 
one of its most common forms. 

Symptoms. — The symptoms of inflammation are divided intone local,. 
comprehending the unusual appearances presented by the inflamed part, 
and the constitutional, affecting the general system. 

Local Symptoms. — The principal local symptoms are the six follow- 
ing : redness, swelling, heat, pain, abnormal exudation, and impairment 
of function. 

I. REDNESS. 

Cause. — This symptom arises from an increased quantity of blood in 
the inflamed part, not only in the larger vessels, but also in the capil- 
laries. The smallest of the capillaries, in their natural condition, are 
invisible to the unassisted eye, and allow only one blood globule to pass 
through at a time ; but in inflammation they become so enlarged as to 
allow several to pass abreast. In some inflammations the redness is 
partly caused by extravasation of blood, but in most instances it depends 
on enlargement of the capillaries, and the consequent increase in the 
quantity of blood contained by them. 

Varieties as to tint, extent, and form. — The tint of the redness varies 
in different inflammations ; in common acute and sthenic inflammation 
it is bright and vivid, and the colour of arterial blood ; in chronic and 
asthenic inflammation it is more of a dark or purple hue ; in erythema 
it is a bright rosy 4 red, and perfectly continuous ; in erysipelas it is of a 
darker red ; in erysipelas attended with great bilious derangement, it is 
of a yellowish red ; in syphilitic inflammations it has something of a 
copper tinge ; in scrofulous inflammation it presents a peculiar soft 

3 



34 



INFLAMMATION. 



appearance ; and when the inflammation is about to result in gangrene, 
it is of a dark purple or blackish hue. 

The extent and form of the redness vary according to the character 
and intensity of the inflammation, and the nature of the tissue princi- 
pally involved. In phlegmon, for example, it is circumscribed, in ery- 
sipelas diffused ; in phlegmon it is gradually and insensibly lost in the 
surrounding parts ; whereas, in the erratic form of erythema, it presents 
a distinctly defined margin, or may be said to be abruptly circumscribed. 
With regard to form, it may be linear, as in inflammation of veins and 
lymphatics ; or punctiform, as in inflammation of the villi of a mucous 
membrane, which is not itself involved ; or ramiform, as when the 
smaller arteries and veins only are seen distended ; or capilliform, as 
when the distension of some of the capillaries is also seen ; or uniform, 
as in erysipelas, when there is one continuous blush of efflorescence. 

The presence or absence of redness is not, by itself, a 'proof of the pre- 
sence or absence of inflammation. — Eedness alone does not constitute 
inflammation ; for it often exists without inflammation, as in the crimson 
spot of the hectic cheek, or in the blush of shame, or when produced by 
friction, or by the application of heat, or by the cupping glasses. On 
the other hand, the absence of redness is no proof that inflammation 
does not exist ; for some inflammations, as those of the cornea and of 
the arachnoid membrane, are attended with opacity instead of redness. 
It is only in conjunction with other local indications that redness is re- 
garded as a symptom of inflammation. The diagnostic peculiarity of 
inflammatory redness is its continuance so long as the inflammatory 
action, which causes it, still remains. 



Cause.- 



Fig. l. 



II. SWELLING. 

-The swelling may, in the early stage of the inflammation, 
be occasioned in some slight degree by 
the increased quantity of blood ; but it is 
chiefly caused by the effusion into the in- 
tervascular spaces of some matters called 
products of inflammation. The nature of 
these matters will afterwards be consi- 
dered. 

The extent of the swelling depends 
partly on the kind and violence of the in- 
flammation, the more violent the action, 
the greater generally being the inflam- 
matory effusion, and partly on the nature 
of the part affected, being greater in loose 
and relaxed textures of a supple and dila- 
table character, such as cellular tissue, than in those of a hard unyield- 
ing nature, such as bones. In loose textures, generally, the swelling is 
most remarkable. 

Fig. 1. Granules and granular masses, filling up the intervascular spaces and coat- 
ing the vessel at a. The transparent nuclei of cells may be seen here and there among 
the granules. Examples of intervascular deposit. Plenty of this will account satisfac- 
torily for swelling. — Bennett. 




INFLAMMATION. 35 

The consequences of swelling vary much according to the impor- 
tance, the delicate nature, the situations and relations of the part affected. 
In textures superficially situated, which do not perform a function of 
great importance, which are loose and dilatable, and so placed that the 
swelling cannot prevent the performance of any function essential to the 
animal economy, the occurrence of swelling is followed by relief, and 
is, therefore, favourably regarded by the surgeon ; whereas, in some 
internal organs, in the sub-mucous cellular tissue of the glottis, and in 
many textures of a delicate nature, a very slight degree of effusion is 
sufficient to lead to a fatal result, and in some firm and unyielding struc- 
tures it not unfrequently causes the total destruction of the part in- 
flamed. The intelligent practitioner, therefore, in forming a correct 
judgment of the consequences likely to result from the effusion of pro- 
ducts of inflammation, will be guided by a consideration of the site, 
relations, nature, and importance of the affected part. 

Of swelling, as a symptom of inflammation, it may be remarked, that, 
like redness, it is generally greatest at the centre of the inflammation, — 
that it is, in most cases, gradually lost in the surrounding parts, — and 
that alone (as may be proved by many examples), it is no certain evi- 
dence of inflammation. 

III. PAIN. 

Pain varies in hind. — There are great varieties in the kinds of pain, 
depending on the part principally affected. It may be of a burning, 
tingling, or pruriginous character, as in certain inflammations of the 
skin, — or throbbing, as when the cellular tissue is affected, — or ex- 
tremely acute, sharp, and lancinating, and greatly increased by stretch- 
ing the inflamed part, as in inflammation of serous membranes ; — some- 
times it is dull, heavy, obtuse, of an exceedingly oppressive character, 
and attended with a feeling of nausea, as in inflammations of some 
glandular organs ; — and sometimes it is of a severe, bursting character, 
as in inflammations of ligaments, fasciae, periosteum, or bone. 

Pain varies in degree. — Pain, in different kinds of inflammation, 
varies much in degree, being, in some kinds, exceedingly intense, so as 
to constitute by far the most urgent symptom, while in others it is com- 
paratively slight. In some inflammations, under certain circumstances, 
there is no pain. Usually the intensity of the pain is in the direct ratio 
of the firmness and unyielding nature of the part affected. For exam- 
ple, ligament, bone, and fasciae, structures which, when sound, are 
endowed with little sensibility, are extremely painful when they become 
the subjects of inflammation. There is generally more pain in external 
inflammations, and in inflammations of the investing membranes, than 
in those which affect the substance of the viscera, or mucous mem- 
branes. In inflammation of some parts of mucous membranes, there is only 
a sense of heat and uneasiness not amounting to actual pain. The pain is 
generally greater in common, than in specific inflammations, with the ex- 
ception of gout. Of inflammation unattended with pain, the following 
examples may be enumerated : — insidious and indolent forms of scrofu- 
lous inflammations, in which extensive disorganization is often produced 
without the patient having ever been conscious of actual pain ; — inflam- 



36 INFLAMMATION. 

mation in a part the subject of paralysis, or succeeding the division of 
the sensitive nerve of the eye, or in cases where the sensibility of the 
patient has been benumbed by the habitual use of intoxicating liquors ; — 
very dangerous inflammations of the lungs in low kinds of typhoid fever, 
and those inflammations which affect the mucous membrane of the uri- 
nary passages, in complete anasthesia of the lower parts of the body. 
The absence of pain, therefore, is no certain evidence that inflammation 
does not exist ; and it is equally true that its presence is no sure proof 
of the existence of inflammation; — of this we have examples in cases of 
neuralgia. There is usually no difficulty in distinguishing between in- 
flammatory and neuralgic pains ; the former are invariably aggravated 
by pressure, whereas the latter are not only not increased, but often re- 
lieved by it. Neuralgic pain is generally intense from the commence- 
ment, and sometimes subsides suddenly; inflammatory pain steadily 
increases while the inflammation advances, having been at first, perhaps, 
nothing more than a slight increase of the natural sensibility. The 
sudden subsidence of pain in violent inflammations is more to be dreaded 
than desired, as it gives good reason to suspect that the part has lost its 
vitality, from the inflammation having gone on to gangrene. 

The site of the pain is generally the site of the inflammatory action, 
but is in some instances at a distance from it ; for example, in inflam- 
mation of the bladder or kidney, the pain is felt at the point of the 
urethra ; in inflammation of the hip joint, it is felt principally at the 
knee ; in inflammation of the diaphragm, or upper part of the liver, the 
pain is at the right shoulder ; in some inflammations of the brain, it is 
felt more along the spine ; and in inflammation of the spinal cord, it is 
sometimes felt along the thorax, and in parts of the limbs, more than at 
the seat of the disease. In all such cases the pain is termed sympathetic, 
and is met with principally in those instances in which the inflamed and 
painful parts are closely connected together by function ; or where the 
latter contain the terminal expansions of nerves whose trunk or branches 
pass through or near the former. To avoid errors in diagnosis, these 
peculiarities as to the site of the pain should be carefully kept in view. 

Cause of Pain. — The pain has been by some ascribed to compression 
of the nerves of the inflamed part by distended vessels and effusion ; by 
others to an exaltation of nervous function, or to a painful stretching of 
the nerves arising from the distension of their small nutritious vessels ; 
and by others to an impression produced on the nervi vasorum by the 
slight dilatation and elongation of the arteries during each impulse of 
the blood. From the facts that the pain is great where the nerves are 
most liable to be compressed, and that it is always increased by pres- 
sure (unless the pressure be steady, uniform, and such as to support the 
whole of the inflamed part), and from other considerations, it seems 
highly probable that pressure is the chief cause of the pain. 

IV. HEAT. 

Preternatural heat is usually characteristic of inflammation, and it 
was no doubt the general presence of this symptom, and an erroneous 
idea of the changes which take place in inflammation, that led to the 
adoption of the term derived from inflammo, to burn. This symptom, 



INFLAMMATION. 37 

like redness, varies much in degree, according to the violence of the 
inflammatory action, and the situation of the affected textures : in acute 
phlegmon, erysipelas, and certain inflammations of the skin and mucous 
membranes, it is considerable, and much complained of; while in some 
inflammations it is so slight as to be scarcely felt at all, or appreciated 
by the patient. 

John Hunter made many experiments and observations to ascertain 
the actual increase of temperature caused by inflammation. He excited 
inflammation in the vagina and rectum of an ass, and in the cavity of 
the thorax of a dog ; and in none of these instances did he ever observe 
the temperature to rise more than one degree above the natural heat of 
the part. He had occasion to operate on a man in St. George's Hos- 
pital for the cure of hydrocele, and on drawing off the fluid he found 
that the thermometer, on being introduced into the cavity of the tunica 
vaginalis, stood at 92° ; the next day, when inflammation had taken 
place, it stood at 98f, being an actual rise of 6f degrees. He observed 
that on applying a blister to the chest, the difference of heat in the in- 
flamed and surrounding parts did not exceed one degree or two ; whereas 
on applying a blister to the extremities, which are naturally colder, the 
difference between the healthy and inflamed parts was found to be from 
five to six degrees. 

These experiments and observations warranted the following con- 
clusions : — That the increase of heat is not so great as the patient 
might by his feelings be led to imagine, nor as a bystander might sup- 
pose before making the experiment ; that the greatest rise of tempera- 
ture is found where the inflamed part is considerably removed from the 
centre of the circulation, and where the natural temperature is several 
degrees below that of the blood at the heart ; that the actual rise of 
temperature in deep-seated parts is not more than one degree, but that 
in parts remote from the centre of circulation it may be several degrees ; 
and that in every instance the heat is below the temperature of the 
blood at the heart. It is in the parts remote from the centre of circu- 
lation that the heat is most complained of. 

The thermometer, however, only measures the degree of actual heat, 
whereas what the patient experiences is the sensation of it ; and when 
we consider that not only is the sensibility of the inflamed part in- 
creased, but that the functions of the nerves also are increased and 
perverted, we need not be surprised that it is sometimes a very distressing 
symptom. An excellent writer on surgery has very happily remarked, 
" The heat of inflammation is partly actual, as ascertained by the ther- 
mometer, partly the result of perverted nervous function, estimated 
only by the patient." 

John Hunter attributed the augmented heat to the increased influx 
of arterial blood. In all cases, animal heat is believed to be derived 
from the mutual action between the oxygen and the carbon and hydro- 
gen of the tissues ; and we may therefore conclude with Liebig, that 
together with an-increased influx of blood, there is an increased amount 
of this kind of combustion, or an unnaturally rapid oxidation of the 
inflamed tissues. 



38 INFLAMMATION. 



V. ABNORMAL EXUDATION. 

In every instance of undoubted inflammatory action, an exudation of 
blood-plasma occurs, and according to the ideas now entertained, this 
symptom is essential to inflammation. On this subject, I cannot deny 
myself the pleasure of giving the following quotation from Dr. Bennett's 
admirable "Treatise on Inflammation." — "Pain, heat, redness, and 
swelling, have been made to play too important a part in our views con- 
cerning inflammation. They are only present when the lesion affects 
the external surface, and are by no means applicable when it attacks 
many internal organs. I have seen cases of encephalitis, where no 
pain or heat was manifested before death, and where no redness or 
swelling was to be afterwards discovered, although an undoubted 
inflammatory softening existed. Inflammation also may attack the 
lungs, liver, kidneys, &c, and yet one or more of these supposed car- 
dinal symptoms be absent. Again, slight incisions as those with a 
razor, are generally supposed to heal by means of inflammation, and so 
they do ; but where is the pain, heat, redness, or swelling ! In short, 
the symptoms of phlegmon, which so frequently come under the notice 
of surgeons, have been by them too generally applied to all inflamma- 
tions. An analysis of these symptoms also will show that, whilst some 
depend upon the previous congestion, others are attributable to the 
exudation that follows it. Thus the heat and redness are caused by 
the former, whilst the pain and swelling usually result from the latter. 
The presence of these symptoms, therefore, cannot be considered as 
essential to inflammation ; whereas the state can never exist, however 
slight, or however severe, without exudation of blood-plasma. Other 
pathologists have felt the difficulties which attend the considering exu- 
dation as a result rather than as the essential phenomenon of inflamma- 
tion. Thus Dr. Alison observes, ' In order to give the requisite preci- 
sion to the general notion of inflammation, as a local change of the 
condition of any part of the body, it seems only necessary to include 
in it, besides the pain, swelling, heat, and redness, the tendency always 
observed, even when the changes in question are of short duration, to 
the effusion from the blood-vessels of some new products, speedily 
assuming in most instances the form, either of coagulable lymph, or 
of purulent matter.' If instead of tendency to we read existence of, 
effusion, the principle laid down is certainly correct." 

VI. IMPAIRMENT OF FUNCTION. 

Impairment or perversion of function is an almost invariable symptom, 
varying much in character according to the organ affected, and the 
degree and progress of the inflammation. In many cases the function 
is first increased, then perverted, and afterwards, entirely arrested. 
Of many examples of this symptom, I shall mention only the following. 
The brain, when inflamed, no longer continues to perform its office, as 
an organ of intellect, having its function at first perhaps exalted as in 
delirium, and afterwards entirely suspended on the supervention of 
coma ; the stomach is incapable, in inflammation, of performing its 
office, as a digestive organ ; the kidney ceases to be useful as a uro- 



INFLAMMATION. 39 

poietic viscus ; the bladder becomes impatient of the least distension by- 
urine, and the eye becomes intolerant of the slightest impression of 
light. The perceptions of taste and smell are lost in inflammations of 
the mouth and nostrils, so that the parts are incapable of performing 
their special functions, while at the same time, their common sensibility 
is often considerably increased, and inflammations of the ear, or of the 
muscles and vessels, the affected parts fail in the performance of their 
proper functions. In internal inflammations, derangement of function 
is frequently an important guide towards forming an accurate diag- 
nosis. 



ances of the blood 



Constitutional symptoms. — The constitutional symptoms may be con- 
veniently arranged into two general divisions : — first, the symptoms of 
cnranrka*liA+TA inflammatory fever ; and second, the inflammatory appear- 
ed. 

I. SYMPATHETIC INFLAMMATORY FEVER. 

Various names have been employed at different periods to designate 
this disturbance in the general system : — it has been called Sympathetic 
Inflammatory Fever, Constitutional Fever, Sympathetic Synocha, Gene- 
ral Vascular Reaction, Constitutional Disturbance, Sympathetic Fever, 
Symptomatic Fever, &c. 

The patient generally has a sense of coldness, rigors, lassitude, and 
feebleness, followed by heat and dryness of skin, and generally by 
increased strength, frequency, fulness, and hardness of pulse. This is 
not, however, invariably the condition of the pulse ; for example, in 
inflammation of the stomach and intestines it is small and exceedingly 
feeble, there being an early and decided depression of the action of the 
heart, occasioned, as is supposed, by the combination of nausea with 
pain ; and in inflammation of the brain attended by coma, the pulse is 
comparatively soft and slow. The respiration becomes hurried, and 
there is often an uneasy sensation of oppression in the chest ; the face 
is flushed, and the head generally hot ; the patient is restless, does not 
sleep well, complains of much general, discomfort, and of dull pains in 
the loins and limbs ; he cannot command his attention, and both the 
will and the power to exert himself are diminished ; he loses his appetite 
and is usually thirsty ; the tongue becomes white, loaded, and dry ; the 
mouth is parched ; the various secretions are deranged and diminished ; 
the bowels constipated, the urine scanty and high-coloured, the func- 
tions of digestion and nutrition interrupted ; emaciation soon becomes 
great, and debility excessive ; there is incapacity for any mental exer- 
tion, and, ultimately, the mind is apt to become confused. 

Sympathetic inflammatory fever is especially marked by the absence 
of certain symptoms which distinguish the different forms of what is 
called idiopathic fever, and more particularly by the absence of petechia, 
of any special eruption on the skin, or the peculiarly overpowering 
depressio febrilis) muttering delirium, subsultus tendinum, and stupor ; 
in short, by the absence of those peculiar signs of derangement of the 
nervous system to which we give the name of typhoid symptoms. 



40 INFLAMMATION. 



II. INFLAMMATORY APPEARANCES OP THE BLOOD. 

When blood taken from a person labouring under inflammation is 
received into a spherical, or into a deep vessel, and allowed to remain 
at rest, the two parts into which it separates itself, namely, the clot, cruor, 
or crassamentum, and the serum, present the following peculiarities : — - 

The clot is firmer and denser than that of healthy blood ; the upper 
surface, which is of less diameter than the lower, is covered over with a 
whitish layer formed of fibrin, constituting what is called the buffy coat, 
and this surface is' sometimes hollowed out into a cuplike form, in which 
case the blood is said to be both buffed and cupped. Under these cir- 
cumstances, the coagulum is usually oval, but truncated at both extremi- 
ties, broader below than above, and often adherent to the bottom of the 
recipient vessel. The coagulable lymph of surgeons, which is observed 
on cut surfaces, is identical in appearance and chemical characters with 
the buffy coat, and they, no doubt are the same substance. The appa- 
rent ratio of the clot to the serum is variable, depending materially on 
the figure of the containing vessel. When the coagulating blood is con- 
tained in a spherical vessel, the particles of fibrin, being little removed 
from a common centre, are more powerfully attracted towards each other, 
yield a denser clot, and squeeze gut more serum than when the coagula- 
tion takes place in a shallow, wide basin, when the particles are spread 
over a large surface. The clot, in the one case, is compact and small ; 
in the other, being spongy and retaining much of the serum, it appears 
to be of a larger size, although the actual quantity of solid matter is the 
same in both. When the blood is sizy, i. e., but slightly changed, the 
clot is, for the most part, cylindrical, and floats in the serum. 

The coagulation of blood taken from a person labouring under in- 
flammation takes place more slowly than that of healthy blood ; ajid to 
this circumstance the formation of the buffy coat has been sometimes 
ascribed. It may, indeed, be assisted by the slowness of coagulation ; 
but it has been proved by many observations to depend principally upon 
some vital change in the blood itself, in consequence of which there is 
an unusual disposition to a separation of the fibrin from the red par- 
ticles, or, as it has been expressed, "to a sort of repulsion between 
them." This is exemplified, as was first particularly pointed out by 
Schroecler van der Kolk, in blood abstracted by venesection during in- 
flammation, and placed so as to form a mere film, so thin as not to 
permit a stratum of the buffy coat to be over a stratum of red particles ; 
when the fibrin and the red particles separate from each other laterally 
by horizontal movements. This separation is distinct and immediate, 
and gives rise to a spotted or mottled appearance, which, like the 
cupped and buffed appearance, is regarded as characteristic of inflam- 
mation. By means of the microscope the separation may be beautifully 
seen in a single drop of inflammatory blood — the red particles become 
aggregated together in the form of rolls, which present an areolar ar- 
rangement, and leave interspaces for the fibrin, "lymph-globules," and 
serum. 

Such are the chief appearances of inflammatory blood. With reference 
to the buffy coat it is to be remarked that its extent varies according 



INFLAMMATION. 



41 



to the violence and duration of the inflammation, and according to the 
character of the texture involved, being much greater in inflammation 
of fibrous and serous textures than in that of the parenchyma of internal 
organs ; and that it is present in certain states unconnected with in- 
flammation, as in the state of pregnancy, in the blood of chlorotic 
females, and in that of persons affected with general plethora. 

LOCAL CHANGES. 

By the aid of a microscope the following phenomena may be readily 
seen in the transparent parts of animals, as in the web of a frog's foot, 
after the application of a stimulus capable of exciting inflammation, such 
as alcohol, or acetic acid. 



Fig. 2. 




I. The capillary vessels are narrowed and the flow of blood through 
them accelerated. This stage is of very short duration, more especially 

Fig. 2. An exact copy of a portion of the web in the foot of a young frog, after a 
drop of strong alcohol had been placed upon it. The view exhibits a deep-seated artery 
and vein, somewhat out of focus ; the intermediate or capillary plexus running over 
them, and pigment-cells of various sizes scattered over the whole. On the left of the 
figure, the circulation is still active and natural. About the middle it is more slow, the 
column of blood is oscillating, and the corpuscles crowded together. On the right, 
congestion, followed by exudation, has taken place, constituting inflammatory action in 
the part. 

a. A deep-seated vein, partially out of focus. The current of blood is of a deeper 
colour, and not so rapid as that in the artery. It is running in the opposite direction. 
The lymph-space on each side, filled with slightly yellowish blood plasma, is very appa- 
rent, containing a number of colourless corpuscles, clinging to or slowly moving along 
the sides of the vessel. 

b. A deep-seated artery, out of focus, the rapid current of blood allowing nothing to 
be perceived but a reddish-yellow broad streak, with lighter spaces at the sides. 

Opposite c, laceration of a capillary vessel has produced an extravasation of blood, 
which resembles a brownish-red spot. 

At d, congestion has occurred, and the blood-corpuscles are apparently merged into 
one semitransparent, reddish mass, entirely filling the vessels. The spaces of the web, 
between the capillaries, are rendered thicker and less transparent, partly by the action 
of the alcohol, partly by the exudation. This latter entirely fills up the spaces, or only 
coats the vessel. — Bennett. 



42 



INFLAMMATION. 



when the stimulus is very powerful ; in which case it may pass so quickly 
into the next as to escape observation. 

II. The vessels become greatly distended, and the flow of blood is 
slower than usual. 

Such beyond all doubt are the first and second abnormal changes 
produced by the application of the stimulus. 

III. The blood flows irregularly: it oscillates, that is, it goes back- 
wards and forwards, and often is absolutely stagnant for a time. In 
the neighbourhood of the parts thus affected the vessels are distended 
and the circulation through them is more rapid than is natural ; and 
over all the affected surface new vessels become visible, the explanation 
of which is believed to be that the red particles are received in 
abundance into vessels which previously contained them in such small 
quantities as not to be perceptible. 

IV. The vessels become greatly distended, and the circulation of 
blood ceases entirely. 

V. Blood becomes effused into the surrounding textures by rupture 
of the vessels, and liquor sanguinis is exuded without rupture. 

VI. Besides these changes in the size of 
the vessels and the movement of the blood, 
others are observed in the relation of the 
corpuscles of the blood to each other, and to 
the walls of the vessels. 

In the transparent parts of animals in the 
natural state, the red corpuscles of the blood 
circulate in the centre of the blood-vessels : 
and on each side there is a space containing 
the liquor sanguinis, and the lymph- cor- 
puscles. Two currents are thus circulating, 
one in the centre, consisting of the red cor- 
puscles, the circulation of which is very 
rapid ; and the other at the sides, consisting 
of the liquor sanguinis with the lymph-cor- 
puscles, the circulation of which is compara- 
tively very slow. In inflammation the fol- 
lowing abnormal changes may be seen. The 
lymph-corpuscles proceed very slowly in the 
lymph-spaces, and some of them become 
parts to the sides of the vessels. The central 
column of red particles, as the vessels distend, becomes enlarged ; the 
corpuscles encroach on the lymph-spaces, and gradually come into 
contact at some parts with the walls of the vessels ; they become 
adherent to each other, so that their individual forms are no longer 
perceptible, and ultimately the vessels giving way some blood becomes 
extravasated, and the liquor sanguinis exudes through the walls of the 
vessels. The exudation of liquor sanguinis constitutes the essential 
phenomenon of inflammation, or in other words, its characteristic or 
pathognomonic feature; while the other phenomena constitute the state 




adherent at certain 



Fig. 3. Two vessels coated with granules, nuclei, and compound granular corpuscles. 
Example of Exudation. — Bennett. 



RESULTS OF INFLAMMATION. 



43 



of active congestion, which is one step short of inflammation. It is of 
importance not to confound congestion leading to inflammation with the 



Fiff. 4. 




inflammation itself. Effusion of serum, capillary hemorrhage, or ex- 
travasation of blood may take place in consequence of other morbid 
conditions ; but in the present state of our knowledge it is believed that 
inflammation never exists without the exudation of liquor sanguinis, and 
that this exudation alone is a proof of inflammation ; it is, therefore, 
regarded as the essential phenomenon of that state. 



TERMINATIONS, RESULTS, OR EVENTS OF INFLAMMATION. 

Certain conditions resulting from inflammation were formerly called 
"terminations of inflammation." But to the use of this expression 
objections have very properly been made, on the ground that several 
of the conditions referred to are co-existent states with the inflam- 
mation, or successive stages in the progress of the same inflamma- 
tory disease, and the inflammation does not cease or terminate when 
these conditions occur. The words results or events, are not liable to 
the same objections, and are now used to denote these conditions. The 
results of inflammation which we have to consider are, Resolution, Effu- 

Fig. 4. a. Colourless globules adherent, b. Blood-disks, still circulating, c. Dense, 
stagnant, homogeneous mass. d. Corpuscles in oscillatory movement, becoming de- 
tached from the impacted mass. — Williams. 



44 EXUDATION OF COAGULABLE LYMPH. 

sion of Serum, Exudation of coagulable Lymph, Suppuration, Ulcera- 
tion, Crangrene, and Sphacelus. 

I. RESOLUTION. 

Resolution is said to occur when the symptoms gradually subside, and 
the liquor sanguinis becomes absorbed, so that no trace of it remains, 
and the part returns in all respects to its former condition and integrity. 
There is in short a subsidence or resolution of the inflammation, and 
this result, therefore, may be properly considered a termination of in- 
flammation. The subsidence may be gradual, when the process is called 
resolution; or it may be sudden without symptoms of inflammation 
appearing in any other part, when it is called delitescence ; or it may be 
sudden and abrupt, and the inflammation may suddenly appear in an- 
other part, and then metastasis is said to take place. 

IT. EFFUSION OF SERUM. 

The liquid is deposited by exudation through the vascular coats yet 
entire, and consists principally of the serum of the blood slightly modi- 
fied, being of higher specific gravity, and containing more albumen than 
in health, with more or less of fibrinous matter. This result is some- 
times seen surrounding an inflamed part, in the centre of which there 
are other results of inflammation, and then the effusion into the areolar 
tissue surrounding the part in a higher grade of inflammation constitutes 
oedema, which is indicated by pitting on pressure. Diffusion of serum 
presents itself in inflammation of serous membranes, as for example, in 
pleuritis, when the quantity poured out is in some instances very great ; 
and in such cases, if the effusion has taken place rapidly, it will be found 
on careful examination that the supernatant portion is usually clear, 
and the deeper portion turbid and more dense, owing to the fibrinous 
portions being of greater specific gravity, and sinking to the bottom. 
In this instance the blood-plasma which exudes separates into the serum 
and fibrin. The appearance, however, of the effusion varies according 
to the acuteness of the inflammatory process. The consequences of 
serous effusion vary much according to the part affected ; in some situa- 
tions it is comparatively harmless, while in others a trifling amount of 
effusion is sufficient to destroy life. 

Serous effusion is often the result of congestion not inflammatory, and 
often of venous obstruction unconnected with inflammation. In every 
instance of undoubted inflammatory action, exudation of blood-plasma 
takes place, and the fluid, when poured into a cavity, is more or less 
turbid, and contains fibrin ; whereas, when unconnected with inflamma- 
tory phenomena, the fluid is clear, and holds no fibrin in solution. 

III. EXUDATION OF COAGULABLE LYMPH. 

Of many examples which could be mentioned of this result of inflam- 
mation, two of the most frequent and striking are to be seen on the free 
surfaces of inflamed serous membranes, and on the edges of cut wounds. 
This has been called the adhesive stage of inflammation, and in wounds 
it leads to the union called by surgeons union by the first intention. In 
inflammation of serous membranes, the appearances presented by the 






SUPPURATION. 45 



coagulable lymph vary according as the inflammation has been more or 
less acute, and in instances where it has been decidedly acute, accord- 
ing as it has been found more or less rapidly fatal. 

The coagulable lymph, at the earliest period, and while it presents 
the gelatinous semitranslucent appearance, seems to consist of filaments 
made up of minute molecules arranged in lines. When the lymph be- 
comes opaque, it appears to consist of the same filaments, larger in size, 
and consequently more distinct but less molecular, together with a quan- 
tity of corpuscles, which, on account of their constituting the charac- 
teristic structure of plastic lymph, have been denominated plastic cor- 
puscles. When the lymph has become consistent, and the fluid part 
has been absorbed, cells, undergoing development into fibres, are obser- 
vable. The filaments in recent lymph are believed to be results of depo- 
sition, and are therefore called primary ; but those in old lymph are 

Fig. 6. 







considered to be the result of cellular development, as originally de- 
scribed by Schwann, and are hence called secondary. In the case of 
cut wounds, exudation of plastic lymph takes place, and cells are de- 
veloped which pass into fibrous formations ; and the result is called 
union by the first intention. Different opinions have been advanced as 
to the mode in which new vessels are formed. Some think that the 
new vessels arise independently of the old, and are in a measure self- 
formed in the plasma, nucleated cells arranging themselves in lines and 
communicating by decadence of their opposing walls, and that the vessels 
thus formed afterwards connect themselves with the old vessels. Others 
are of opinion that blood-corpuscles escape from the original vessels 
adjacent, and hollow out for themselves channels in the plasma, and 
that these are, by and by, succeeded by others in a continuous stream. 

IV. SUPPURATION. 

This term is used to denote the transformation of the exuded matter 
into pus, a result most commonly found in cellular tissue, constituting 
an abscess, on the surface of granulating sores, and on the mucous mem- 
branes. Normal pus, such as that formed in phlegmonous abscess, or 
that yielded by healthy granulating sores, is an opaque, creamy, straw- 
coloured, or slightly greenish fluid, having a peculiar mawkish odour, 

Fig. 5. Nuclei developing themselves into fibres. — Bennett. 
Fig. 6. Cells developing themselves into fibres. — Bennett. 



46 



SUPPURATION. 



Fig- 7. 




which it loses on cooling. On examination of its minute structure, it is 
found to consist essentially of two distinct parts ; numerous minute 
organized particles, called pus-corpuscles, and a clear yellowish liquid, 
named the liquor puris, in which the corpuscles are suspended. 

The form of the pus-corpuscles, in genuine pus, is perfectly spherical, 
with a finely granulated surface ; they vary in size from l-100th to 

1-T5th of a millimetre in diameter ; in pro- 
portion as the pus deviates from the normal 
type, varieties are observed both in the form 
and size of the globules. When the cor- 
puscles are examined in heaps^ they exhibit 
a yellow tint ; but when separately, they 
appear colourless. They are organized forms, 
and consist of a nucleus, cell-wall, and con- 
tents. The nucleus is for the most part 
composed of several granules, generally two 
or three, but sometimes four or five, and is 
hence called a composite multiple nucleus. 
It is not placed in the centre of the cell, and 
is usually attached to its inner surface. 
On the addition of water, the pus-corpuscles become increased in size 
and more transparent, and they usually lose their finely granulated sur- 
face. Weak acetic acid partially, and strong acetic acid completely 
dissolves the cell-wall, and by that means the nucleus can be brought 
clearly into view. 

The pus-corpuscles may be formed either from fluid cytoblastema, as 
in the fluid secretion of fresh wounds, in suppuration on the surface of 
the body after burns or blisters, and in suppurations on mucous mem- 
branes, as in catarrhs and gonorrhoea ; or from a solid cytoblastema of 
fibrin after coagulation : — in other words, pus may be formed from fluid 
blood-plasma before coagulation, and also from exuded matter rendered 
solid. On the formation from fluid cytoblastema, Vogel remarks : — " The 
process of the formation of pus from a fluid cytoblastema can be best 
observed in fresh wounds cleansed from blood. In examining the fluid 
secretion from a wound, we first observe minute granules, less than the 
1000th of a line in diameter, which are chemically identical with the 
molecules insoluble in the alkalies and in borax. There then appear, 
partly around these molecules and partly independent of them, some- 
what larger corpuscles, soluble in the alkalies but not in acetic acid, 
identical with the nuclei of the pus-corpuscles. These nuclei appear some- 
times isolated, sometimes in groups of twos or threes, thus forming corpo- 
rate nuclei ; around these the cell-wall is subsequently developed, first 
appearing as a pale transparent membrane, and subsequently becoming 
thickened and granular ; and thus the pus-corpuscle is formed. The pro- 
duction of pus-corpuscles in this manner is tolerably rapid ; in the course 
of three or four hours after the first appearance of the nuclei perfect cor- 
puscles may frequently be seen : in other cases the process is slower." The 
formation of pus-corpuscles from a solid cytoblastema of coagulated fibrin 



Fig. 7. a. Natural appearance of pus-corpuscles, 
acetic acid. 



b. Appearance after application of 



ABSCESS. 47 

is a process of frequent occurrence, as, for example, in abscesses in 
which the coagulated fibrin is changed into fluid pus, in cases in which 
pus is formed from the solid exudations from serous membranes, and in 
numerous other instances where a solid blastema is rendered fluid by the 
formation of pus. After the formation of the pus-corpuscles, the fibrin 
of the cytoblastema is exhausted, and the serum of the pus resembles 
greatly the serum of the blood. Pus-corpuscles are incapable of passing 
into permanent structures, or of undergoing a higher development, or of 
conversion into a more perfect organism. 

When purulent matter is confined in the parenchyma of a part, in a 
cavity which is not natural, it constitutes an abscess ; when infiltrated 
through the structures of an organ, the condition is termed purulent 
infiltration ; when the purulent matter is formed on a mucous membrane, 
from which it is voided externally, the patient is said to have a purulent 
discharge ; and when the matter forms an accumulation in some regular 
and natural cavity, the case is said to be one of purulent effusion, or of 
suppuration in that cavity. 

Abscesses may be either acute or chronic. 

ACUTE ABSCESS. 

Symptoms. — When inflammation is about to lead to the formation of 
abscess, the symptoms which at first are the usual local and constitutional 
symptoms of inflammation, undergo a degree of aggravation. In many 
instances, however, the suppuration does not proceed so far as to pro- 
duce sympathetic inflammatory fever. The pain becomes of a distressing 
pulsatory character, and often after the formation of matter it changes 
into an uneasy feeling of weight, or of heaviness and pressure ; redness 
and tension, after being very great, are diminished, and the swelling, on 
being examined, presents different characters at different stages of the 
inflammation ; being at first tense and hard in the middle, and oedema- 
tous around, and afterwards soft in the centre, hard at the circumfe- 
rence, and oedematous at a still greater distance from the centre of 
inflammation. When the swelling becomes raised up and prominent at 
one part, it constitutes the condition technically called the pointing of 
the abscess. In general, some time before the abscess points, fluctua- 
tion is discoverable, and this, taken in conjunction with the other symp- 
toms, is one of the surest signs of the presence of matter, as it can only 
exist when there is fluid. At an early stage, however, when the super- 
imposed structures are still thick and tense, and the quantity of matter 
but scanty, the perception of fluid is obscure, but it becomes more and 
more distinct, as the textures intervening between the abscess and the 
surface of the body become thinner. To discover whether fluctuation 
be present, the fingers may be pressed alternately on the swelling, or 
( which is preferable) the fingers of one hand may be applied to one side 
of the swelling, while, with the finger of the other, the opposite side is 
tapped, and the undulations of the pus will be distinctly perceived. 
Some surgeons greatly excel others in detecting the presence of matter. 
This skill is of great importance, and every surgeon should endeavour to 
acquire it in the greatest possible degree. 

The tactus eruditus, as it is called, may be acquired by any one who 



48 ABSCESS. 

has experience, and acuteness of the sense of touch, together with the 
valuable talent of using them aright. When suppuration is deeply 
seated, so that fluctuation and pointing are not discernible, there are 
other symptoms (provided the inflammation be to a considerable extent), 
•which afford pretty certain evidence of the formation of matter : — these 
are shiverings, technically called rigors, before the suppuration occurs, 
and after it has taken place, a change from the acute pain in the part 
to a feeling of weight, or numbness, or pressure, or some sensations 
totally different from those experienced during the acute inflammation. 
Antecedently to suppuration there is frequently interruption of the 
proper performance of the function of some organ, and if the abscess be 
deeply seated and large, the pulse ere long becomes feeble and increases 
in frequency ; the patient becomes emaciated, and the constitutional 
symptoms are rapidly changed from those of inflammation to those of 
hectic fever. 

The condition of the parts. — The condition of the parts in acute 
abscess may be stated to be : — suppuration, where fluctuation is per- 
ceptible ; deposition of fibrin around the pus, offering a barrier to infil- 
tration of pus into the surrounding textures, and constituting the 
hardness at the circumference ; and, serous effusion into the parts ex- 
ternal to the barrier of fibrin, giving rise to oedema, evidenced by pitting 
on pressure. 

Treatment. — To remove general and local causes of excitement and 
irritation, and to promote the approach of the matter toward the surface, 
are important indications in the treatment of abscess. The best means 
of fulfilling these indications, are the strict observance of antiphlogistic 
regimen, perfect rest of the affected part, strict maintenance of a proper 
attitude, the removal of all sources of irritation, as well as of tension, or 
pressure, and the diligent use of warm emollient poultices, hot fomenta- 
tions being applied each time the poultice is removed. Purulent matter 
having once been formed, it may be stated as a general rule in the 
treatment of acute abscess, that the grand indication then to be fulfilled 
is the early and free discharge of the matter. In some circumstances 
very early attention to this rule is of the utmost importance ; as in 
abscesses under dense aponeuroses, and under thick fasciae (as, for ex- 
ample, under the temporal aponeurosis, or under the tendon of the occi- 
pito-frontalis muscle, or under the fascia of the thigh, of the leg, of the 
arm, or of the fore-arm, or under the palmar or plantar fasciae), within 
tendinous sheaths, as in paronychia tendinosa, or underneath the peri- 
osteum, as in paronychia periostei, or under the pericranium, in the 
proximity of bones, in the natural cavities, or in the texture of bones ; 
also in abscesses arising from the extravasation of irritating fluids, as 
collections of matter caused by the extravasation of urine into the cel- 
lular tissue of the perineum and scrotum ; abscesses in parts abounding 
with cellular tissue, when there is great risk of the spreading of the in- 
flammation, or in situations where there is danger of making their way 
into some of the natural cavities, as into the chest, or abdomen, or the 
joints ; or such as are likely to occasion injury by pressing upon or im- 
peding the functions of important parts, as the trachea, the pharynx, 
the urethra ; or abscesses, in highly vascular and sensitive parts, where 



ABSCESS. 49 

the pain of an abscess is often most excruciating. With scarcely more 
than one exception, early and free opening of an abscess is the proper 
course ; but in the above-mentioned conditions, it is peculiarly necessary 
to adopt this proceeding at the earliest possible period after we are cer- 
tain of the actual existence of matter : for not only are time and suffer- 
ing saved and tissue preserved by its adoption, but by its neglect the 
danger of most destructive local results is increased, and in some cir- 
cumstances, even the loss of life itself may result. Almost the only 
condition in which it is proper to delay opening, is in cases of glandular 
enlargement, in which, when other means have failed to produce absorp- 
tion, and suppuration has occurred, the opening should be deferred, that 
the pressure of the matter may more effectually secure the disintegra- 
tion and breaking up of the glandular structure, and thereby favour its 
removal, 

Of the various methods of opening abscesses I shall refer to only two ; 
namely, by means of a bistoury, and by means of caustic. The former 
is preferable, except in two conditions, presently to be mentioned. It 
consists in making a free, direct opening in a depending situation, and 
as already stated, at an early period. In the event of the matter 
making its way in a different direction, a second opening should be 
made, which, from often being opposite to the first, is called a counter- 
opening. By making an early, large, direct opening in a depending 
situation, and keeping it open while matter continues to be secreted, the 
formation of sinuses, loss of substances, and disintegration are generally 
prevented, and the desired result is attained more speedily, and with 
less suffering than it would be by any other proceeding. 

The two conditions in which opening by means of caustic is preferable, 
are the following : — 

1. In small abscesses, partaking of a chronic character, where the 
integuments are attenuated in consequence of the opening having been 
delayed, or where they are in a diseased state. In such cases the inte- 
guments are too much weakened to take on the necessary action for 
uniting with the subjacent parts ; and as no healing process takes place 
until they are destroyed by ulceration, it is better to destroy them at 
once, and make a free opening by means of caustic. For this purpose 
the potassa fusa is preferred, and is applied so as to destroy the whole 
of the diseased and thinned integument. 

2. In cases of glandular enlargement in the state of abscess, in which 
condition the caustic should be used very freely, and be pressed into the 
gland in different situations, so as to lead to the action by which the 
diseased structure may be separated and removed. 

CHRONIC ABSCESSES. 

Collections of matter sometimes form slowly and insidiously, and the 
symptoms of inflammation which precede them, are but slightly, if at 
all, perceptible ; in such cases, the abscesses are said to be chronic. 
These collections often attain a great size ; there being little fibrin 
effused around the matter, the sac is thin, and the resistance to exten- 
sion feeble ; they are frequently irregular in form, and the superimposed 
skin remains unaltered in colour. 

4 



50 ULCERATION. 

The treatment of chronic abscess is a matter of great anxiety to the 
intelligent surgeon, in consequence of the danger, lest the opening of 
the sac should be followed by violent irritative fever, which has a ten- 
dency to merge very speedily into hectic fever. Where such collections 
are small, the patient's health tolerably good, and his constitution not 
very susceptible of inflammatory action, the treatment proper for acute 
abscesses, namely, free, direct incision, may be ventured upon ; but as 
the danger of this proceeding is considerable, the surgeon is only justi- 
fied in resorting to it in the conditions mentioned above. In all other 
cases, the treatment should consist in drawing off the matter by small 
valvular tapping — in closing up the wound so as to prevent the admis- 
sion of air, by the presence of which, the opposite sides of the sac would 
be separated from each other, the putrefaction of the remaining matter 
promoted, and much constitutional disturbance induced, — in preserving 
the sides of the sac in contact, by gentle support, — and in renewing 
the valvular opening, before any great reaccumulation has taken place, 
so that the sac may not be allowed to regain anything like its former 
size, each opening being made with the observance of the same precau- 
tions as in the first instance. Sometimes, although very rarely, after 
the first operation the cavity contracts, and the desired result is ob- 
tained ; but more frequently several repetitions of the operation are 
required, before the disease is cured ; and in some instances, after the 
sac has become very much contracted by the adoption of the above pro- 
cedure, it becomes safe to resort to the treatment for acute abscess, 
namely, free, direct incision, for perfecting the cure. The best appa- 
ratus for this mode of treatment consists of a long trocar, a canula 
furnished with a stop-cock, and a fine exhausting syringe which fits the 
canula. About an inch and a half or two inches from the spot where 
the sac is to be opened, a small aperture should be made in the skin ; 
through this the trocar is to be inserted, carried under the skin, and 
sent through the sac where it is to be opened ; the trocar should be 
withdrawn, the stop-cock being shut before it is completely removed ; 
the syringe should be applied to the canula, and the matter drawn off, 
care being taken to shut the stop-cock after each stroke of the syringe. 
Gentle pressure should be applied to the sac, and while the canula is 
being withdrawn, pressure should be applied over its track, to prevent 
the admission of air ; the opening should be closed up very carefully by 
means of plaster, and be preserved close, until adhesions have taken 
place. Rest, and every judicious precaution should be strictly enjoined, 
for some time after each operation, to diminish the danger of inflamma- 
tion of the sac. This treatment is, in my opinion, the safest that has 
yet been proposed for this form of abscess, and by means of it, a favour- 
able result is occasionally obtained ; but in many instances, these ab- 
scesses are connected with incurable diseases of the bones or joints ; 
and, as patients live much longer in such cases, when the abscesses are 
not opened, there can be no doubt whatever, that, under these circum- 
stances, it is the duty of the surgeon to let them alone. 

V. ULCERATION. 

This is a frequent result of inflammation. Great differences are ob- 
served in the different tissues, with respect to their tendency to ulcera- 



ULCERATION. 51 

tion, when they become affected with inflammation, and these differences 
have important pathological bearing. It is most common in the skin, 
mucous membranes, cellular tissue, and the other tegumentary mem- 
branes ; it is frequently met with in bones, and the inner coats of 
arteries, but is very rare in fibrous tissues of all kinds, in serous mem- 
branes, in the outer coats of arteries, and in nervous tissue. The pro- 
cess of ulceration, according to the views now entertained, is very 
clearly explained in the following quotation from Dr. Bennett's admi- 
rable "Treatise on Inflammation." — " The process of ulceration is some- 
what similar to that of mortification, only it is more chronic, and the 
exudation, instead of undergoing decomposition, only exhibits an indis- 
position to pass into organization. In this case, the exudation is 
poured out slowly, it coagulates, and presses upon the surrounding 
parts, more or less obstructing the flow of blood to them, and acts as a 
foreign body. By means of the continued pressure, the circulation is 
obstructed, and death of the portion affected results. Sometimes this 
is imprisoned in fresh exudation, as ulceration extends, and the whole 
at length becomes disintegrated. All this time, the exudation exhibits 
little of that tendency so conspicuous in healthy persons, to undergo 
changes in itself, and when examined microscopically, is found to con- 
sist principally of very minute granules, varying in size from the 12000 
to the 5 Jo of a millimeter in diameter. These are occasionally mixed 
with irregularly-formed cells, usually more or less angular, containing 
one or more granules. The cells are more numerous, in proportion to 
the stage of the ulceration, and the healthy powers of the constitution. 
These different granules and imperfect cells, with the structures they 
involve, at length become broken down, and separate from each other, 
constituting a semi-fluid mass, which has a tendency to point where it 
can most readily be discharged, that is, towards the surface of the skin 
or mucous membranes. Here, on account of the less degree of re- 
sistance offered, the continued pressure and disintegration of tissue 
first cause an aperture to be formed. Another portion of solid exudation 
is now broken down with the tissues involved in it, and in this way the 
opening is enlarged. If the morbid process continue, a fresh exudation 
is slowly poured out below the already coagulated blood-plasma, which 
supplies the loss thrown off in the form of discharge, and thus chronic 
ulceration may be increased indefinitely. The whole of this process 
may be well observed in scrofulous and syphilitic ulcers, or in the cal- 
lous sores of the leg in weavers, and others of a cachectic constitution. 
Indeed, the general powers of the constitution are almost always in such 
cases enfeebled, and hence the indisposition of the exudation to be trans- 
formed into organized cells. Ulcers produced by direct pressure are 
occasioned in a similar manner ; only in most cases the pressure is not 
derived in the first instance from solid exudation poured out. Thus in 
stumps, not sufficiently covered by soft parts, in places long pressed 
upon by lying, or by the growth of tumours, the vitality of the part is 
slowly destroyed. At the same time an exudation is poured out from 
the neighbouring vessels, which becomes broken up, and assists in dis- 
integrating the textures, whose vitality is destroyed. The finely mole- 
cular particles are thus absorbed, whilst the grosser portions are thrown 
off in the form of discharge." 



52 ULCERATION. 

G-ranulation. — The process by which the cavity is filled up, and con- 
tinuity of tissue restored, is called granulation : it consists in exudation, 
from the surface of the cavity, of blood-plasma, constituting the fluid 
cytoblastema. Part of this blood-plasma degenerates into pus-corpus- 
cles, but part becomes transformed into nucleated cells. Minute gra- 
nules, forming the nucleoli (as they are called) are developed, and to the 
assemblage of these the term nucleus is given. On the nucleus, a cell- 
wall becomes developed, which, at first, closely embracing the nucleus, 
is afterwards raised up from it, and the nucleus thus separated from the 
cell-wall occupies an eccentric position within it. In these organized 
products vessels are formed, and the whole, when thus developed, con- 
stitutes a layer of granulations, spreading over the surface of the cavity, 
and giving it the appearance of being covered with innumerable small 
bodies of a conical form, and of a florid red colour. From the granula- 
tions blood-plasma is exuded, part of which degenerates into purulent 
matter for the defence of the granulations, and part is transformed 
into nucleated cells, by which a new layer of granulations is formed. 
The cells of the first-formed layer undergo further changes, and 
are ultimately developed into the texture of the part, from the vessels 
of which the exudation of blood-plasma took place, and each subse- 
quent exudation furnishes a cytoblastema for the formation of puru- 
lent matter and nucleated cells. By the successive formation of 
these cells, by their becoming ultimately developed into permanent 
tissue, and by the centripetal contraction of the original textures, the 
cavity is filled up, and the next part of the process is cicatrization, or 
the formation of cicatrix. This usually begins when the granulations 
arrive on a level with the surrounding skin, when the blood-plasma, 
hitherto converted partly into pus-corpuscles, and partly into nucleated 
cells, passes into cells which, by the process of development, are con- 
verted into fibres, and constitute the cicatrix. The new skin usually 
takes its rise from the margins of the old skin ; but in some few instances, 
portions of new skin are seen forming on the surface of the granula- 
tions, like little islands, quite remote from the margins. Some have 
endeavoured to account for this fact, but the supposition that the old 
skin has not been completely destroyed, as we not unfrequently find in 
burns, and that the isolated portions of new skin spring from the parts 
not entirely destroyed by the burn or ulceration ; but I am convinced 

Fig. 8. 




by various cases which have come under my own observation, that this 
explanation is not satisfactory. I shall only refer to one case, that of 
a young lady, whom I had the opportunity of seeing, together with one 
of my colleagues in the University. The lady was the subject of pha- 



ULCERS. 



53 



gedgenic ulcer, of considerable size and of great depth, in the leg ; and 
as other means had had no effect in arresting the destructive action, the 
whole surface was destroyed to a considerable depth by pure nitric acid. 
After the removal of the slough, healthy action took place, and a large 
isolated portion of the skin formed in the middle, and gradually increased 
until it joined that formed from the circumference of the ulcer. I have 
for several years been in the habit of showing to my class in the Uni- 
versity, a drawing of this case, as it is an incontrovertible instance of an 
exception to the ordinary rule of the formation of skin from the circum- 
ference only, and an evidence that the explanation mentioned above is 
not satisfactory. 

ULCERS. 

An ulcer may be defined — a solution of continuity caused by ulcera- 
tion. Future chapters will give a description of specific ulcers, that is, 
ulcers caused by a specific poison, as syphilitic ulcers, and those con- 
nected with particular diatheses, such as the scrofulous, the scorbutic, 
or the cancerous. Other ulcers, not coming under either of these divi- 
sions, we shall, for the sake of clearness, arrange into seven varieties, 
namely : — 1st, healthy ulcer ; 2d, weak ulcer ; 3d, indolent ulcer ; 4th, 
inflamed ulcer ; 5th, phagedenic ulcer ; 6th, gangrenous or sloughing 
ulcer ; and 7th, sloughing phagedena. 

In describing the appearances of ulcers, we shall refer to the state of 
the edges, the granulations, and the discharge. 



Fie. 



I. HEALTHY ULCER. 

The healthy ulcer, the simple, and the simple purulent, ar 
names given to the same ulcer. 

Characters of a healthy ulcer. — The edges 
are smooth, neither inverted nor everted, and 
adhere to the granulations, and when the 
latter rise to a level with the common integu- 
ment, a semi-transparent white film of cica- 
trix fringes round the edges, and gradually 
spreads over the granulations. The granula- 
tions are small, florid, firm, numerous, and 
pointed at the top, vascular, apt to bleed on 
being touched, sensitive, and attended with a 
slight feeling of tenderness instead of uneasi- 
ness or pain. When the granulations come 
to be on a level with the integument, they 
begin to be covered over by cicatrix. The 
discharge is thick and purulent, and easily 
separated from the surface of the sore. 

Treatment. — The treatment consists in pre- 
serving the part at rest, maintaining such an 
attitude as will promote venous return, and 
prevent unpleasant sensations and conse- 
quences from tension, and in defending the 
part from the action of the air. Of the 
various means adopted for fulfilling this last- 



e different 




54 



ULCERS. 



mentioned indication, the most elegant is tepid water-dressing, applied 
by means of a small bit of lint with a piece of oiled silk over it to 
prevent the lint from being dried. The frequency of the dressing 
should depend on the quantity of the discharge ; it being unneces- 
sary to change it more frequently than is requisite to preserve the 
parts perfectly clean and comfortable. Another application still em- 
ployed by some is simple ointment ; but, for my own part, I almost 
invariably, like many others, give the preference to the tepid water- 
dressing, with a small piece of oiled silk, and a few turns of a bandage 
to afford gentle support when necessary. 

II. WEAK ULCER. 

Characters. — In the weak ulcer, called by many writers the fungous 
ulcer, the granulations, instead of being like those described in the cha- 
racters of the healthy ulcer, are much larger, paler, flabby, less nume- 
rous, not pointed on the top, but, on the contrary, sometimes even bul- 
bous, less vascular, less apt to bleed on being touched, less sensitive, 
unattended with pain, and when they have filled up the cavity of the 
ulcer, they rise up above the level of the surrounding integument, so 
that the margins are sometimes at this stage overlaid by them, and 
concealed from view. The edges are smooth, and the discharge is pale, 
and thinner than in healthy ulcer. 

Fie. 10. 




Treatment. — A necessary part of the proper treatment consists in 
removing, if possible, the cause ; and, in addition to this, suitable means 
are to be adopted for removing the effects. The cause of the ulcer 
assuming the characters above described may be general, operating on 
the system at large, such as, a deficiency in the quantity or nutritive 
quality of food, an unwholesome atmosphere, a weak or disordered con- 
dition of the digestive apparatus, the debilitating effects of mental 
anxiety, or feebleness of constitution, however induced ; or the cause 
may be local, such as improper treatment, as, for example, the use of 
relaxing applications, venous congestion caused by some obstacle to the 



ULCERS. 55 

return of the blood, or a weakened condition of the parts occasioned by 
the nature of the injury of which the ulcer is the result, or the delay of 
cicatrization, for perfectly healthy granulations become weak when 
healing is by any cause delayed. With regard to local treatment, rest 
should be enjoined, and an attitude favourable to venous return ; 
together with the careful application of gentle pressure by uniform 
bandaging, which acts as a gentle stimulant to the granulations, and 
corrects the tendency to passive congestion. The use of a medicated 
water-dressing of a stimulant nature, instead of plain tepid water-dress- 
ing, should also be adopted. Solutions of the sulphate of zinc, or the 
sulphate of copper, varying in strength from one to two grains, or even 
more, to an ounce of water, generally answer most satisfactorily in the 
treatment of this ulcer. I usually prefer the solution of the sulphate 
of zinc, either the simple solution, or medicated with two drachms of 
the compound spirit of lavender and a drachm of the spirit of rosemary 
to eight ounces of water. The lotion should be kept applied by means 
of a little lint, with a piece of oiled silk placed over it to prevent drying, 
and at the same time bandaging should be employed, not merely as in 
healthy ulcer for retentive purposes, but to secure gentle and uniform 
pressure. 

Other modes of treatment which have been adopted are, pressure 
together with the application of dry lint to the granulations as a dress- 
ing, shaving off the fungous granulations with a knife, and destruction 
of them by escharotics. The treatment already described will very 
rarely be found to fail in producing the desired effect ; but when it does 
fail, recourse may for a short time be had with advantage to pressure, 
with a dressing of dry lint. 

III. INDOLENT ULCER. 

Characters. — The form of this ulcer is seldom irregular, but usually 
nearly oval or circular. The edges are thick, prominent, comparatively 
insensible, glossy, smooth, firm, incompressible, and without any appear- 
ance of cicatrix; the surrounding parts are also firm, hard, incompres- 
sible, and usually discoloured by passive congestion ; the surface of the 
ulcer is nearly devoid of granulations, is smooth and glossy, and varies 
in colour, being in some examples whitish, in some gray, and in others 
brownish. The discharge is scanty, thin, and watery. This ulcer may 
be said to be almost exclusively confined to the labouring poor, occurring 
in their lower extremities, and after the middle period of life. 

Treatment. — An important indication, as may readily be imagined, 
in the treatment of this ulcer, is to improve and maintain the general 
health and strength ; and with this view, generous diet, residence in an 
airy situation, and the due regulation of the digestive organs should be 
prescribed, together with the use of tonics in many instances, and even 
of stimulants, when indicated by the particular circumstances of the 
case. Of many different modes of treatment I shall refer only to two, 
namely, that suggested by Mr. Baynton, and that by Professor Syme. 
Of these the former has hitherto been generally regarded with favour, 
and has received the general adoption of the profession. When it is 
carefully conducted, its results are very satisfactory. The following is 



ULCERS. 



Mr. Baynton's description of his method of treatment : — " The parts 
should be first cleared of the hair, sometimes found in considerable 
quantities upon the legs, by means of a razor, that none of the dis- 

Fig. 11. 




charges, by being retained, may become acrid and inflame the skin, and 
that the dressings may be removed with ease at each time of their 
renewal, which in some cases, when the discharges are profuse and the 
ulcers very irritable, may perhaps be necessary twice in twenty-four 
hours, but which I have in every instance been only under the necessity 
of performing once in that time. The plaster is to be cut into slips 
about two inches in breadth, and of a length that will, after being passed 
round the limb, leave an end of about four or five inches. The middle 
of the piece, so prepared, is to be applied to the sound part of the limb, 
opposite to the inferior part of the ulcer, so that the lower edge of the 
plaster may be placed about an inch below the lower part of the sore, 
and the ends drawn over the ulcer with as much gradual extension as 
the patient can well bear ; other slips are to be secured in the same 
way, each above and in contact with another, until the whole surface of 
the sore and the limb is completely covered at least one inch below and 
two above the diseased part. The whole of the leg should then be 
equally defended with pieces of soft calico, three or four times doubled, 
and a bandage of the same, about three inches in breadth and four or 
five yards in length, or rather, as much as will be sufficient to support 
the limb from the toes to the knee, should be applied as smoothly as 
can possibly be performed by the surgeon, and with as much firmness 
as can be borne by the patient. It is to be first passed round the leg 
at the ankle-joint, then as many times round the foot as will cover and 
support every part of it except the toes, and afterwards up the limb till 
it reaches the knee ; observing that each turn of the bandage should 
leave its lower edge so placed as to be about an inch above the lower 
edge of the fold below it." The success of this method of treatment, 
when applied in suitable circumstances, is generally acknowledged. 
Callous ulcers are often presented for treatment in an inflamed state ; 
soothing applications should in such circumstances be prescribed, until 
that condition be removed, and the treatment above described may then 
with propriety be resorted to. One great advantage of this method of 
treatment is, that perfect rest and constant elevation of the limb are 
not so essential auxiliaries as in other methods ; and this is, in some 
circumstances, a matter of great importance. The good effects of this 
mode of treatment are properly ascribed to pressure, which, by pro- 
moting absorption of the swelling, favours the contraction requisite for 



ULCERS. 57 

cicatrization. The merit of first pointing out the beneficial effects of 
pressure in the treatment of this ulcer is due to Mr. Whateley, who 
applied pressure by bandages alone ; that of prescribing adhesive 
plaster, together with the use of a bandage, belongs to Mr. Baynton. 

Professor Syme's treatment consists in the application of a blister 
sufficiently large to cover the ulcer, and a portion of the surrounding 
parts. In favour of this mode it is urged, that it is more speedy and 
more economical than Baynton's ; but as the risk of erysipelas is con- 
siderable, and as the first effect is to enlarge the ulcer (which is far 
from desirable, although it may improve its character), it has always 
appeared to me, that as a general practice, the method of Baynton is to 
be preferred : at the same time, however, I am perfectly aware that 
satisfactory results are often obtained by the adoption of that of Syme. 

IV. INFLAMED ULCER. 

Characters. — The edges and surrounding parts are red, swollen, hot, 
tense, tender, and painful ; the surface of the sore is destitute of granu- 
lations, and presents a raw and pulpy, or a foul and livid appearance ; 
the discharge is profuse, offensive, and often streaked with blood, mingled 
with ulcerative debris. The pain is great, and there is always more or 
less constitutional disturbance. 

Fig. 12. 




Treatment. — The object aimed at in the first instance being the con- 
version of the inflamed, into a simple, healthy ulcer, undue irritability 
and excessive action must be first subdued ; and for this purpose general, 
as well as local, treatment must be instituted. The diet should be care- 
fully regulated, and the secretions of the digestive organs, and of the 
skin, be brought into a proper state by purging, antimonials, calomel, 
and opium, or such other remedies as seem to be indicated by the parti- 
cular circumstances of the case. With regard to local treatment, per- 
fect immunity from motion, the observance of an attitude calculated to 
promote venous return and relaxation, are absolutely indispensable ; of 
local applications, the most useful are warm poultices and fomentations, 
or opiate poultices, and opiate fomentations ; in short, heat with mois- 
ture, or heat and moisture combined with opiate applications, are the 
most soothing remedies. Simple poultices, or poultices medicated with 
decoction of opium, are very useful and grateful in such cases. Local 
depletion by leeches, or scarification of the edges of the ulcer, is some- 
times resorted to, but it is very seldom indeed that such a proceeding is 
necessary. 



58 



ULCERS. 



V. VI. VII. PHAGEDENIC ULCER. — GANGRENOUS ULCER.- 
PHAGEDENIC ULCER. 



•SLOUGHING 



The characters and treatment of the phagedenic and the gangrenous 
ulcers, and of sloughing phagedena will be minutely described in the 
chapter on the state of constitution in which they are most frequently 

Fig. 13. 




observed ; but their characters may be briefly stated in this chapter. 
The three varieties — namely, phagedena or phagedenic sore, sloughing 
or gangrenous sore, and sloughing phagedena, called by some writers 

Fig. 14. 




the phagedena gangrenosa, are so similar to each other in the circum- 
stances in which they are found, in their symptoms and in their treat- 
ment, that it will be more convenient to describe them together than to 
assign a separate section to each. The term phagedena, derived from 
<p«/w, to eat, is well applied to this kind of ulcer, as there is the appear- 
ance of regular eating away, or destruction by phagedenic ulceration, 
without any attempt at granulation. 

Phagedena, or a phagedenic ulcer, may be distinguished by the fol- 
lowing peculiarities. The edges are extremely irregular, and of a dark 
purplish appearance, a red colour extending a considerable way into the 
surrounding parts ; they are exceedingly painful, and at parts inverted ; 
the surface of the sore is uneven, and extends underneath the edges ; it 
is of a livid or dark red colour, and, together with the edges, has a very 
irritable appearance. It is covered by a thin, ichorous, bloody discharge. 
The sore enlarges with alarming rapidity ; and the destructive process 
may continue to be carried on, by ulceration alone, or by ulceration 
together with sloughing, so as to constitute the variety called by some 
writers the sloughing phagedena, and by others the phagedena gan- 
grenosa. In the other variety, namely, the sloughing sore, the destruc- 
tion is by sloughing alone ; the sore enlarges by the formation of one 
slough after another, and the surface of the sore on the separation of 
the slough, has a raw, red, irrritable appearance. These three varieties 



MORTIFICATION — GANGRENE — SPHACELUS. 59 

exhibit the same appearance of edges, and occur in similar circum- 
stances ; they differ chiefly in the appearance of the surface of the 
sore ; there being in the phagedenic sore an irregular appearance of 
the surface, occasioned by the ulcerative process ; in the sloughing pha- 
gedena the same appearance at some parts, and a wet ash-coloured 
slough at others ; and in the sloughing variety a wet slough covering 
the sore. The characters of these ulcers are so peculiar that there can 
be no difficulty in distinguishing them from each other, or from any of 
the other varieties of ulcers. A high degree of constitutional disturb- 
ance attends each of these varieties. The constitutional symptoms and 
treatment will be given in a future chapter. 

GANGRENE AND SPHACELUS. 

The three terms — Mortification, Gangrene, and Sphacelus, have been 
indiscriminately used by some authors to express an important result of 
inflammation, namely, the death of the part. In the use of them here, 
we shall follow the guidance of those who regard mortification as a 
generic term comprehending the whole series of phenomena, from the 
first diminution of the vital powers to their entire destruction ; gan- 
grene, as denoting the stage in which there is diminution but not per- 
fect destruction of the powers of life ; and sphacelus, as denoting the 
complete death of the part. 

Local and Constitutional Symptoms of Gangrene and Sphacelus from 
Inflammation. — In gangrene the redness is changed into a dark or 
livid hue ; the heat, sensibility, and pain are diminished ; the swelling, 
though not diminished, but sometimes even increased in extent, is less 
tense, and generally pits on pressure ; and on different parts of the 
surface we usually find portions of the cuticle elevated into small blis- 
ters, called phlyctene, containing unhealthy serum of a yellowish or 
greenish colour. These symptoms do not indicate an entire extinction 
of the vital powers, and, consequently, the part sometimes recovers, or 
only a very small portion of it becomes dead. Generally, however, the 
symptoms of gangrene merge into those of sphacelus, in which the part 
presents a black, a dark, or an ash-gray colour, according as it is more 
or less exposed to the. atmosphere ; it becomes cold, and not only ceases 
to be painful, but entirely loses its sensibility ; instead of having the 
appearance of excessive distension, as in the inflammation preceding 
the occurrence of gangrene, it becomes soft, flaccid, and shrunk in its 
dimensions : it crepitates on pressure, and emits a peculiar cadaverous, 
characteristic odour. Such are the local appearances of the sphacelated 
part. This part is called the slough, and the process by which it is 
formed, sloughing. When the mortification has a disposition to spread, 
the dark colour extends, and is insensibly lost in the surrounding parts ; 
whereas, when the mortification ceases to spread, a red line, called the 
line of demarcation, separates the sphacelated from the living parts. 
This line is, in the living part, in immediate contact with the dead, and 
its appearance is always regarded as most important, as indicating not 
only that sphacelation or sloughing has ceased, but also that a process 
has been commenced by nature for the removal of the sphacelated part 



60 GANGRENE — SPHACELUS. 

from the system. In this process, exudation and partial organization 
of fibrin precedes suppuration and ulceration, and thus hemorrhage from 
vessels, and infiltration into loose tissues, are both prevented. As the 
process advances, the cuticle is separated from the line of adhesive in- 
flammation, and the part exhibits the appearance of a circular vesicle ; 
this gives way, and an inflamed and ulcerated surface is then brought 
into view, called the line of separation. The continuity of the parts 
being thus fairly interrupted, the furrow deepens and extends, till the 
sphacelated portion is entirely detached, leaving, generally, a healthy 
granulated surface. In this very remarkable process, there are various 
results of inflammation, namely — adhesion, which effects two purposes, 
preventing both hemorrhage and purulent infiltration, — ulceration and 
suppuration ; the ulceration being for the purpose of effecting the sepa- 
ration. The process is the same, whether it extends only to a certain 
depth below the surface, or whether the whole thickness of the part 
perishes. In the latter case, remarkable as this process is, the surgeon 
does not leave to nature the work of amputation, partly on account of 
the length of time that would be required, and partly because of the 
irregularity and form of the stump that would be left, as the ulceration, 
in these circumstances, does not proceed perpendicularly to the surface, 
but in a slanting direction, leaving the bones uncovered. To obtain, 
therefore, a more useful stump, the surgeon resorts to amputation. 
The question of amputation, and the time and site that ought to be 
selected when it is advisable, will be considered in a subsequent chapter. 
Local changes in inflammatory Mortification. — Dr. Bennett, to whom 
the profession is much indebted for his valuable " Treatise on Inflam- 
mation," gives the following description of the condition of the parts in 
inflammatory mortification. " Occasionally a very large amount of blood- 
plasma is thrown out, constituting a violent inflammation ; a greater or 
less number of capillaries are also ruptured, and blood-corpuscles are 
more or less mixed up with the liquor sanguineus exuded. The exuda- 
tion thus formed compresses the part, so as to obstruct the blood-vessels, 
and prevent the continuation of any circulation in it. Under these cir- 
cumstances, instead of forming a blastema for the production of new 
organisms, it undergoes chemical changes, which induce in it decompo- 
sition, and the part is said to be mortified, or to be affected with moist 
gangrene. This change commences first in the blood extravasated, 
which becomes of a purple colour, more or less deep ; corpuscles break 
down and become disintegrated ; their hematosine dissolves, and colours 
the serum, and should the exudation have coagulated, it forms brown, 
rust-coloured, purple or blackish masses. An acrid matter is now formed, 
which, acting on the neighbouring tissues, produces fetid gases, that are 
abundantly given off from the affected part. Sulphuretted hydrogen is 
evolved, which causes the blackish sloughs usually observed in such 
cases, and discolours silver probes, and the preparations of lead. After 
a time, the elementary tissues surrounding or involved in the exudation, 
become more or less affected. The transverse striae, in the fasiculi of 
voluntary muscles, become first pale, and are then obliterated. Cellular 
tissues, fat, and other soft substances, lose their connexion, and fall 
into an undefined granular mass. The tendons and fibrous tissues retain 



GANGRENE — SPHACELUS. 61 

their characteristic structure for a long time after the other soft parts 
have been reduced to a softened pulp. The bones resist the action longer, 
but at length become rough, soft, and commencing externally, are more 
or less broken down, and reduced to the same pulpy consistence, and 
granular structure, as the surrounding parts. As the tissues thus be- 
come broken down and fluid, they are discharged from the system in the 
form of an ichorous matter, which, examined microscopically, presents 
numerous granules, imperfect or broken-down cells, blood-corpuscles, and 
fragments of filamentous tissue or other structures involved." 

Constitutional symptoms of inflammatory Mortification. — During the 
inflammation which precedes the mortification, and when a disposition to 
form a line of demarcation is observed, the constitutional symptoms are 
those of inflammatory fever ; but when the mortified part is of great 
importance in the animal economy, or when the mortification is exten- 
sive, the constitutional symptoms very speedily merge into those of the 
worst typhoid type. Some of the principal symptoms are the following : — 
the pulse is rapid, thready, and feeble, in some instances irregular, and 
in others intermitting ; but the most striking peculiarities of the pulse 
are great diminution of strength, and great increase of frequency, and 
before death it becomes exceedingly indistinct and flickering ; the pa- 
tient lies on his back ; the countenance is cold and has an expression of 
great anxiety ; the features are pinched, and the face has a peculiar 
livid hue ; the tongue is at an early period furred and dry in the middle, 
and ultimately the whole of the mouth exhibits the same condition ; hic- 
cup comes on, and occasionally vomiting of a substance of a coffee-colour ; 
the patient is often observed picking at the bedclothes ; the skin is at 
first dry, but as the case advances it becomes cold and clammy ; on 
pressing the hand to it, it feels raw, and is so relaxed, that on the hand 
being raised up, it gives the impression of sticking to the hand so as to 
follow it slightly and be raised up from the subjacent parts ; the perspi- 
ration, like the other secretions, has a peculiar cadaverous odour ; the 
evacuations are passed involuntarily ; the patient sometimes retains his 
mental faculties to the last, but more frequently he is affected with low 
muttering delirium. Such are the symptoms that precede the closing 
scene in many examples of death from inflammatory mortification. 



62 



CHAPTER II. 

ERYTHEMA AND ERYSIPELAS. 

I. ERYTHEMA. 

In this chapter it is proposed to give a brief but comprehensive ac- 
count of the doctrines of Erythema and Erysipelas. To render the 
description more clear, we shall refer to the different varieties of those 
affections, stating their symptoms and causes, together with the cir- 
cumstances under which they are usually met with, and their treat- 
ment. 

Erythema (from ££«%«*, redness) is a term to which all writers have 
not been careful to affix the same signification. Hippocrates used it to 
denote any kind of morbid redness of the skin ; at a subsequent period 
Celsus, and still later, Galen substituted the term erysipelas for ery- 
thema, and this has, no doubt, occasioned part of the confusion which 
has arisen in the use of the term ; some others, employing it as synony- 
mous with idiopathic erysipelas, others to designate the slightest grade 
of erysipelas ; while some, as J. P. Frank and J. Frank, have applied 
it to several affections of a chronic kind, perfectly distinct from those 
to which it has been given by recent British and French pathologists. 

Erythema, in the sense in which the term is generally employed in 
this country, may be defined to be a superficial redness. of the skin, dis- 
appearing momentarily on pressure ; usually of an acute character, and 
not infectious ; attended with a burning pain, tenderness, and dryness 
of the part, and generally unaccompanied with vesication, or with swell- 
ing beyond a slight and barely perceptible degree. On the subsidence 
of the inflammation the part is covered with scales, in consequence of 
desquamation of the cuticle. 

The idiopathic, or primary, or local, form generally proceeds from 
some topical irritation, as friction, attrition of contiguous surfaces, 
pressure, irritation caused by morbid secretions, by vicissitudes of tem- 
perature, by chemical or mechanical irritants, or by stings of insects. 
Even this form of erythema, although caused by topical irritation, is 
favoured by, and almost always more or less associated with, disorder 
of the digestive, excreting, or eliminating organs. The increased action 
very rarely rises beyond the grade of active congestion ; and the slight 
form of the local affection, its non-extension to the cellular tissue under 
the skin, and the very limited amount of constitutional disturbance, suf- 
ficiently distinguish erythema from erysipelas. 

In this form the proper local treatment consists in the removal of 
the cause of irritation, rest, an attitude favourable to venous return, 



ERYSIPELAS. 63 

and fomentations ; and should these prove insufficient, in pencilling 
over the part with a strong solution of the nitrate of silver. Rest, 
restriction of diet, and a few gentle alterative aperients, constitute the 
general treatment ; and for preventing the return of the disease, the 
most important precautions are, to avoid exciting causes of the affection, 
and to use proper means for regulating the functions of the stomach, 
the liver, and the skin. 

The sympathetic erythema of Rayer may be said to comprehend the 
different varieties enumerated by Willan and Bateman ; these are the 
six following : — erythema fugax, which appears upon the breast, arms, 
and face, in cases of bilious diarrhoea, in certain affections of the ali- 
mentary organs, and in various febrile disorders : erythema loeve, which 
is most frequently met with as an accompaniment to anasarca or oede- 
matous swellings, but occasionally attends the catamenia in weak and 
irritable females, and is sometimes symptomatic of disorder of the 
digestive system: erythema marginatum, which, deriving its name from 
being bounded on one side by a hard, elevated border, occurs chiefly in 
old persons in the progress of some internal disorders, and is always 
regarded as an unfavourable symptom : erythema papulatum, sometimes 
attended with general disturbance of a slight nature, but frequently 
with anorexia and much prostration of strength : erythema tuberculatum, 
a very rare variety attended with great languor, irritability, and rest- 
lessness, and succeeded by hectic (Bateman never met with this variety, 
and Willan only saw three examples) : and erythema nodosum, which 
shows itself in vivid patches on the foreparts of the legs, mostly in 
young females of a relaxed constitution ; is preceded by slight febrile 
symptoms, and is sometimes connected with the approach of the cata- 
menia. 

Rayer mentions another variety which other observers have over- 
looked — general erythema. A case came under my notice some time 
ago, which I believe was an example of this variety : the pulse was 
rapid and feeble, the redness was pretty general over the body, there 
was great prostration of strength, the tongue was dry, and the bowels 
very loose ; it continued nearly a week, and was followed by desqua- 
mation. 

The different varieties of symptomatic erythema must all be treated 
by internal or constitutional remedies, and according to indications 
furnished by the internal disorders which they are found to accompany. 

II. ERYSIPELAS. 

Names and Definition. — Erysipelas, derived from l^«», I draiv, and 
weAces-j adjoining, so named from its tendency to spread to the adjoining 
parts of the skin, may be defined to be an inflammation of the skin and 
subjacent cellular tissue, characterized by a deep-red tint, by swelling 
of the parts affected, and by a remarkable tendency to spread by con- 
tinuity. It is also called the Rose, from the colour of the integument, 
and St. Anthony's Fire, a name given to it in former ages on account 
of the burning heat which accompanies it, and from the belief that St. 
Anthony had special power to heal this kind of disease. 

Divisions. — The varieties of erysipelas have been very differently 



64 ERYSIPELAS. 

divided by different writers. Some have proposed a division according 
to the region in which the disease appears: — 1st, Erysipelas of the face 
and head ; 2d, Erysipelas of the trunk ; and 3d, Erysipelas of the extre- 
mities. Burserius suggested a division according to the supposed 
causes : — 1st, Primary, or Idiopathic, when it arises from an internal 
disease not preceded by any other ; 2d, Symptomatic, or Secondary, 
when it supervenes on another disease ; and 3d, Accidental, when ex- 
cited by some obvious external cause. Biett and Cazenave divide them 
into True and Phlegmonoid ; . Alibert and Bayer into Simple, Phlegmo- 
nous, and (Edematous. The division employed by Willan and Bateman 
was into Phlegmonous, (Edematous, Gangrenous, and Erratic ; and that 
by Desault into Phlegmonous, Bilious, and Local. We shall refer to 
the following varieties : — 1st, Simple ; 2d, Phlegmonous ; 3d, (Edema- 
tous ; 4th, Bilious ; 5th, Erratic ; and 6th, Periodic. 

SIMPLE ERYSIPELAS. 

Symptoms. — Simple, called by some authors true or legitimate 
erysipelas, is characterized by the following symptoms : — Bedness of 
the skin, more or less vivid, occasionally partaking somewhat of a livid 
and in many instances of a yellow tint ; disappearing under the pressure 
of the finger, but returning on its removal ; and defined by a distinct 
elevated margin, which irregularly circumscribes it ; slight tumefaction, 
never acuminated or convex ; and pain of a tensive, peculiar, or stinging 
character, accompanied by itching, and a sense of burning diffused over 
the whole inflamed surface. For three or four days these symptoms 
continue to increase in intensity, and then begin to decrease, remaining, 
however, in some degree for three or four days longer. When the 
inflammation is acute, small miliary vesicles, like those of eczema, 
are developed on the inflamed skin, and when it is very intense 
bullae or phlyctenae often appear on the erysipelatous part. These 
bullae may be isolated or confluent ; they burst soon after their ap- 
pearance, most frequently about the fifth or sixth day of the disease, 
and the humour they emit dries on the skin, forming flavescent crusts, 
which afterwards become brown or blackish, and ultimately are detached 
along with the epidermis, which falls off in scales. 

The local symptoms usually make their appearance after certain 
precursory signs, such as languor, lassitude, depression, shiverings, 
general uneasiness, nausea, and very frequently other manifest symp- 
toms of disturbance of the functions of the alimentary canal. The con- 
stitutional symptoms take the precedence for some time ; then the local 
symptoms appear, and afterwards they increase and decrease together. 
It has, however, been correctly remarked by careful observers, that the 
local disorder is by no means invariably in the direct ratio of the se- 
verity of the febrile symptoms. 

Results. — The most frequent and most favourable result of this form 
of erysipelas is resolution ; slight discoloration and thickening of the 
skin, together with desquamation of the epidermis, remaining for a very 
short time, and then disappearing. In the very mildest form there is 
scarcely any desquamation, but in more acute cases it is considerable, 
and slight thickening of the skin and discoloration remain for a short 



EKYSIPELAS. 65 

time ; and if the action be still more intense, serous effusion may take 
place, both on the external surface of the cutis, constituting bullae or 
phlyctenae, and in the subcutaneous cellular tissue, which becomes infil- 
trated. By the absorption of the fluid in the cellular tissue, and the 
bursting and desiccation of the vesicles on the surface, all traces of the 
disease disappear. At a certain stage, in some cases, the part is found 
to be covered over with dry cuticle, and, in others, where bullae have 
formed, with crusts. Sometimes, though very rarely in this form, and 
only when the action is very acute, the inflammation proceeds to the 
extent of suppuration, forming abscesses; the matter in such cases 
being surrounded by a fibrous cyst, does not constitute diffuse suppura- 
tion, which condition is met with in a more serious variety of erysipelas. 
Although abscess is comparatively unusual, as an immediate result of 
this simple form of the disease, it is by no means uncommon for 
persons of a feeble and irritable constitution to have inflammation ex- 
cited in a part recently the subject of erysipelas, or in its immediate 
neighbourhood, and for that inflammation to go on to the formation of 
abscess, requiring very early and free evacuation, in order to prevent 
destruction of tissue. 

Sometimes the inflammation suddenly disappears, and presents itself 
in some other part of the external surface, constituting erratic or am- 
bulant erysipelas ; and sometimes, although more rarely, its sudden 
disappearance is followed by asthenic inflammation of some internal 
part, constituting metastatic erysipelas. 

Causes. — The causes of erysipelas are various, and sometimes very 
obscure. The chief predisposing causes are intemperate living, espe- 
cially addiction to spirituous liquors, unwholesome or insufficient nour- 
ishment, the bilious and irritable temperaments, the gouty diathesis, 
previous disease, general cachexia, low spirits, anxiety, the feeble, ple- 
thoric, and leucophlegmatic habits, disordered condition of the biliary 
and digestive organs, certain seasons of the year, more especially, 
spring and autumn, irritability or tenderness of the skin, feeble capil- 
lary circulation, previous attack of the disease, and in females certain 
periods of life, as that of menstruation, and that of the cessation of the 
catamenia. Of the many exciting causes some act locally, as wounds, 
contusions, trifling injuries, surgical operations, abrasions of the cuticle, 
irritation caused by morbid secretions, or by leech-bites, or by cold, or 
by friction of clothes, or by acrid or irritating substances of any kind, 
or by inflammation of the skin, from whatever cause proceeding. Of 
the exciting causes which originate in the system itself, and of those 
which act on the system generally, some are errors in diet, violent 
mental emotions, suppression of accustomed secretions or discharges,, 
living in an unwholesome atmosphere, more especially in cold, damp, 
stagnant situations, atmospheric vicissitudes, impure air from the 
crowding together of patients in hospitals, contagion, and particular 
conditions of the air, in consequence of which it occasionally assumes 
an epidemic character, and is in such circumstances usually very 
severe and frequently fatal. 

Erysipelas no doubt comes on in many instances without any obvious 
cause, but that it often spreads by means of contagion has been proved 



66 ERYSIPELAS. 

by incontestable evidence. There seems also to be good ground for 
believing that erysipelas originating in some common cause, and erysi- 
pelas induced by local causes may spread by means of contagion. Most 
of the French authorities deny that erysipelas is transmissible by con- 
tagion ; but that it is so, facts recorded by Dr. Wells, Dr. Stevenson, 
Mr. Arnot, Dr. Gibson, and Mr. Lawrence, in various interesting papers 
published by them on this subject, furnish most conclusive evidence, and 
set this question at rest. Many other cautious observers have arrived 
at the same conclusions on this subject as the authorities I have 
mentioned. 

PHLEGMONOUS ERYSIPELAS. 

This disease, although met with at all periods of life, and in all parts 
of the body, is much more commonly found in young and plethoric than 
in elderly persons, and more frequently in the extremities than in the 
other regions of the body. This is a very dangerous form of the dis- 
ease, especially when it occurs epidemically, or from infection. Both 
the local and constitutional symptoms are severe ; the inflammation not 
only has its seat in the skin and subcutaneous cellular tissue, but fre- 
quently extends also to the deeper portions of cellular tissue between the 
muscles. To make the description of this disease more clear, we shall 
adopt the arrangement of those authors who divide it into three grades, 
differing from each other in the degree of their intensity. 

In the first grade, after rigors, anxiety, and other symptoms of con- 
stitutional disturbance, soon followed by stinging pain, tingling, redness, 
and a feeling of heat of the inflamed part, tumefaction of rather a hard 
character takes place, occasioned by the integument being raised up by 
swelling of the subjacent cellular tissue. After pressure with the 
finger, the redness returns more slowly than in the simple and superfi- 
cial form of erysipelas. If about the fifth day, the skin is observed to 
be less red and tense, and to be covered with furfuraceous scales, and 
the subsidence of the swelling shows that the subcutaneous cellular tis- 
sue is beginning to regain its usual state, the phlegmonous erysipelas 
will end in resolution. But if, on the contrary, the pain at this stage 
becomes pulsatory, suppuration is the inevitable result, the matter form- 
ing into an abscess of healthy character, the opening of which is usually 
followed by the speedy healing of the part. 

In the second grade, both the constitutional and local symptoms are 
much more severe ; the disease occupies a large extent ; at a variable 
period, but generally not before the fifth nor after the ninth day, puru- 
lent collections form beneath the skin or between the muscles, and, on 
their being opened, gangrenous masses of the cellular tissue are dis- 
charged along with the .matter. Often, instead of abscesses, there is 
extensive sero-purulent infiltration into the cellular tissue. There are 
many sources of danger in this variety, some of which are great irrita- 
bility of the stomach and bowels, exhaustion from diarrhoea or from 
extensive suppuration and disorganization of the cellular tissue, severe 
nervous symptoms, contamination of the blood from absorption of the 
morbid secretion of the affected part, or combinations of these condi- 
tions. 



ERYSIPELAS. 67 

In the third grade, the constitutional and local symptoms are still 
more intense from the commencement ; the skin is tense, shining, and 
of a dark dusky red, and only retains, for an instant, the impression 
made by the finger ; the swelling is diffused, very great, and intolerant 
of pressure. About the fifth or sixth day, the skin loses its sensibility, 
assumes a violet tint, and becomes flaccid and covered over with phlyc- 
tense containing a reddish serosity, and, soon afterwards, sloughs are 
formed along with ichorous suppuration, destruction, and suppurating 
boils in the surrounding cellular tissue. This is what some authors call 
gangrenous erysipelas. In the most favourable cases, after the sloughs are 
detached, the subjacent parts take on a healthy action, and, after a con- 
siderable time, the part granulates and cicatrizes : but most frequently, 
from absorption of matter or inflammation of veins, or some affection of 
the brain, stomach, or bowels, the patient sinks, the precursor of death 
being the symptoms of the worst form of adynamic fever. 

EDEMATOUS ERYSIPELAS. 

In this form the skin is smooth, shining, and of .a pale red colour, 
which, in some instances, inclines somewhat to a yellowish brown ; the 
heat and pain are less than in the other forms ; the swelling is conside- 
rable, and gradually extends ; it leaves the impression of the finger as 
in anasarca, and from this circumstance this variety has received its 
distinctive appellation. Vesication is less common than in the other 
varieties, and, when it is present, the vesicles are small and numerous. 
The inflammation is of a subacute character, and gives rise to serous 
effusion ; in some situations it is apt to result in gangrene, as when it 
occurs in dropsical limbs from excessive distension, or when punctures 
have been made to allow the fluid to drain off. To diminish the risk of 
the occurrence of gangrene, in such circumstances, some have judiciously 
allowed the fluid to escape by numerous punctures with a needle, rather 
than by incisions. 

This form of erysipelas is in degree intermediate between the simple 
and phlegmonous, and most commonly presents itself in persons of a 
debilitated constitution, and very frequently in those who have a ten- 
dency to, or are affected with, dropsy. The infiltrated limbs of dropsi- 
cal patients, the scrotum in men, and the genitals in women, are the 
most usual seats of cedematous erysipelas ; and, of all the results of this 
variety, gangrene is the one most to be dreaded, and is indicated by 
severe pain, and a red, glossy state of the skin passing into a leaden or 
lurid hue. 

BILIOUS ERYSIPELAS. 

Antecedent disorder of the digestive and assimilative organs is more 
or less evident in all the forms of erysipelas ; but in this form symptoms 
of bilious derangement, both before and during the attack, constitute 
the most prominent features. In such cases, the local symptoms are 
far from urgent ; the redness partakes much of a yellowish hue, and all 
the local signs indicate but a slight grade of inflammatory action. The 
constitutional symptoms also exhibit a very moderate degree of the in- 
flammatory type ; the principal being nausea, bilious vomiting, loathing 



68 ERYSIPELAS. 

of food, thirst, loaded tongue, a yellowish tinge of the body, and other 
manifest signs of disordered secretions in the prima via. 

ERRATIC ERYSIPELAS. 

The peculiarities of this form are — that it invariably presents itself 
in persons of a feeble or debilitated constitution, that the constitutional 
symptoms precede and attend the attack, and that they are much more 
of the asthenic than of the sthenic character, the symptoms of debility 
usually becoming very apparent ; that the local symptoms are even less 
severe than is usual in ordinary cases of simple erysipelas ; that, in 
most instances, exfoliation is the only effect remaining, and that the 
inflammation spreads from one part to another by continuous unbroken 
extension, the circumference of the inflamed part being always distinct, 
so that it is very evident where the inflamed and unaffected parts of the 
skin join each other. 

PERIODIC ERYSIPELAS. 

The peculiarity of this form is not merely that it returns, but that it 
is sometimes strictly periodical, returning more frequently (so far as my 
observation has enabled me to form an opinion) to the parts which were 
previously attacked ; in some instances it has been found to be periodi- 
cal in return, and universal in extent — that is, extending over the whole 
body ; an example of which occurred in the experience of Mr. Maul, of 
Southampton, in the case of a lady who had several attacks at intervals 
of two years. In some instances the attack is monthly, at the time the 
catamenia should appear. This form of erysipelas is, I believe, most 
frequently met with in females of a weak and chlorotic habit. I have 
a patient who, for some years, had a return of it every six weeks, but 
got over the tendency by residence in the country, and the use of 
suitable remedies for the improvement of her general health and strength. 
I know an instance of a man who had for years an attack every two 
months. In both the last-mentioned cases, the head was the part 
attacked. One man, whose case I remember, had an attack regularly 
twice a year, and another every spring. The local symptoms, so far as 
I have had opportunity of observing, are not very severe, and rarely 
give rise to more than oedema of the cellular tissue, and exfoliation of 
the cuticle. The constitutional symptoms are both antecedent and 
attendant. 

TREATMENT OF ERYSIPELAS. 

From what has been stated regarding the various forms of erysipelas, 
the different states of the system in which they take place, and the 
varieties, both as to the .degree of the inflammatory action, and as to 
the degree and type of accompanying fever, it must be very clear that 
it will be necessary to modify the treatment according to the particular 
circumstances of each form and case. Some cases require little treat- 
ment beyond rest, suitable regimen, and a proper attitude of the inflamed 
part ; in some, purging and the antiphlogistic regimen are needful ; in 
some, local remedies of a decided character must be joined to general 
antiphlogistic treatment ; while others are attended with so much of a 



ERYSIPELAS. 69 

typhoid type as to require the use of remedies of a very different 
nature. It has been well observed: — "In some instances large deple- 
tions are required ; in others, moderate or local depletion only is advi- 
sable ; and, in many, depletion is most injurious, the most energetic 
tonics being often indispensably necessary." Whilst the disease thus 
requires, from the very commencement, most varied and often opposite 
modes of treatment, it frequently, also, demands an almost equal diver- 
sity at different stages of its progress. 

In simple erysipelas, the general treatment in slight cases consists in 
the observance of the antiphlogistic regimen, and the exhibition of mild 
purgatives, together with rest, cool air, and the maintenance of a proper 
attitude ; but in more severe cases, emetics, purgatives, and antimonials 
are to be employed, and, in some instances, early general depletion. 
With reference, however, to depletion, great regard must be paid to the 
powers and habits of the patient, the stage of the disease, and the pre- 
vailing character of the epidemic. Of the many cases which have come 
under my own observation, in comparatively few have I thought general 
bleeding necessary, or at all likely to be serviceable ; and, except in 
some very severe cases of erysipelas in the head and face in young and 
vigorous persons, I very rarely indeed resort to it. Even in such cases, 
and in others where, from the exceedingly acute character of the symp- 
toms, depletion may be deemed prudent, it should be employed with 
much circumspection ; for however strong and hard the pulse may be, 
or however great the heat and the urgency of acute inflammatory symp- 
toms, there is soon, in most cases, a tendency to asthenic vascular action 
and deficiency of vital powers. It is, therefore, judicious in most in- 
stances, to rely on other means for allaying excited action, and to 
resort to bleeding only when it seems absolutely indispensable. In 
most cases, rest, an emetic, mercurial and other purgatives, followed 
by antimonials, and aided of course by suitable regimen, fulfil the 
desired indications, which are to correct the secretions in the alimentary 
canal, to promote the secretions generally, and thereby to diminish in- 
flammatory action and febrile excitement. As the indications of treat- 
ment often alter very quickly, cases should be watched with the greatest 
care, and the treatment changed, if symptoms of debility present them- 
selves. If any doubt exist whether it be desirable to administer decided 
stimulants, beef-tea may be given, and four or five grains of carbonate 
of ammonia every two or three hours ; and if the symptoms should not 
improve, then wine may be administered, and the bowels regulated by 
mild aperients, but not by drastic purgatives. 

The following extract from Mr. Liston, as to the means recommended 
for subduing inflammatory action in erysipelas without resorting to 
bleeding, will be perused with interest : — 

" The exhibition of the extract of aconite in this and other inflamma- 
tory affections, is often followed by great abatement of vascular excite- 
ment, so that the necessity for abstraction of blood is done away with. 
The medicine may he given in doses of half a grain in substance, or dis- 
solved in pure water, and repeated every third or fourth hour. The 
sensible effect is relaxation of the surface, and frequently profuse per- 
spiration ; the arterial pulsations are diminished in frequency and force. 



70 ERYSIPELAS. 

The extract of belladonna, in doses of j$ of a grain, may then be sub- 
stituted with great advantage, and often with the most extraordinary 
effect upon the disease." — Liston's "Elements of Surgery," Second 
Edition, p. 61. Erysipelas. — For report of cases of erysipelas thus 
treated, see " Reports of North London Hospital," contained in the 
" Lancet" of 6th and 13th of February, and 16th of April, 1836. 

Local treatment. — In mild cases no local treatment is required, 
beyond rest, and an attitude favourable to venous return. In others 
local applications are useful. Of all the applications in use, my ex- 
perience leads to the conclusion, that the most generally grateful to the 
feelings of the patient, and the most useful are warm opiate fomenta- 
tions, or opiate and lead lotion, applied as warm as the patient can bear 
them, and as long as he finds them pleasant to his feelings. Sometimes, 
though very rarely, warm applications are painful ; and then I do not 
hesitate, if the erysipelas be in the extremities, to use the above appli- 
cations cold, and if they give relief, to continue their use as long as they 
prove a comfort to the patient. 

In more urgent cases, when the action is very acute, I have, together 
with the use of warm applications, adopted, with the happiest results, 
the mode of proceeding which was proposed by Dobson, and has been 
much and deservedly praised by many, namely, local depletion by 
numerous small punctures, rapidly made with a fine lancet. The punc- 
tures should extend only into the true skin, and should be made rapidly. 
Of the advantages of this proceeding, in acute cases, I can speak in the 
strongest terms, patients having often expressed themselves grateful for 
the relief it has afforded. Other local remedies, used in many cases 
with much advantage, are, brushing over the part with a strong solution 
of the nitrate of silver (as recommended by Higginbotham, and practised 
by many), or lightly touching the inflamed surface with the lunar caustic 
in substance. The former mode is that which I have usually preferred, 
and my experience leads me to speak very favourably of it, especially 
in erysipelas of the extremities. After brushing over the part with a 
strong solution of the nitrate of silver, dusting the surface with flour or 
magnesia, keeping it fomented with warm opiate, or lead and opiate 
lotions, or applying them cold, when warm applications are not grateful, 
are all proceedings from which, in my own experience, I have seen the 
happiest results. I am satisfied from my own observation, that Higgin- 
botham, Jobert, and others, were fully justified in speaking so strongly 
as they have of the advantages of using the nitrate of silver as a local 
application in the treatment of erysipelas. Of the advantage of keeping 
the part covered with mercurial ointment, as proposed by Little and 
Dean of America, or of the application of a lotion, or ointment of the 
sulphate of iron, in the proportion of a drachm of the sulphate of iron 
to a pint of water or an ounce of lard, as recommended by Velpeau, 
principally in cases where there are no vesications, and where the in- 
flammation is superficial, I can say nothing from my own observation. 
To the use of blisters, first recommended by Dupuytren, I have rarely 
resorted, and to bandaging never, except as a means of support when 
all inflammatory action has ceased; but some continental surgeons have 
adopted a proceeding, which, so far as I know, has never been followed 



ERYSIPELAS. 71 

in this country- and which must surely be attended with great risk, 
namely, bandaging from the very commencement of the attack, even 
when the action is acute. 

In phlegmonous JE?ysipeIas, the constitutional and local treatment, in 
the first instance, differs in no respect from that proper for severe cases 
of simple erysipelas ; but it must be strictly kept in view, that whatever 
may be the activity of the symptoms in the early stage, the general 
powers are weak, that the disease not unfrequently occurs in- those 
whose powers are naturally feeble, or in persons advanced in life, and 
that the disease, although accompanied with excitement in the early 
stage, is afterwards marked by impaired energy, so that if the powers of 
the patient be greatly exhausted, he will be in the greatest possible 
danger of sinking under the process of suppuration and sloughing. The 
most important part of local treatment is the employment of incisions, 
which, though suggested centuries ago, was first practised in this country 
by Mr. Copland Hutchison, and has been strongly recommended by him, 
by Mr. Lawrence, and by many others, and is well worthy of general 
adoption. Mr. Hutchison recommends that the incisions be made about 
an inch and a half in length, from two to four inches apart, varying in 
number according to the extent of surface occupied by the disease. 
Mr. Lawrence recommends, in preference to numerous incisions, one or 
two long incisions in a direction parallel to the axis of the limb. Much 
difference of opinion has prevailed, as to which of these recommenda- 
tions should be followed ; but, on this point, the judicious course surely 
is for the surgeon, while he is careful to confine incisions to parts where 
the erysipelas has the phlegmonous character, and, avoids all unneces- 
sary division of parts, to proportion both the number and the depth of 
the incisions to the extent of the inflammation ; and a very important 
rule is to divide fasciae, provided the inflammation extend beneath them. 
The treatment by incisions is adopted at different stages of the disease 
for the attainment of different objects. At the beginning of the disease 
it is employed with great advantage, and is often very quickly followed 
by relief of the painful tension, and a corresponding diminution of the 
inflammatory action, thus preventing the occurrence of suppuration and 
sloughing. In short, suffering and tissue are both spared by the ener- 
getic adoption of this proceeding at an early stage. The local depletion 
is useful, the liquor sanguinis is allowed to escape before its disor- 
ganization has taken place, and disastrous results are averted. At a 
more advanced period of the disease, incisions limit the extent of sup- 
puration by opening a way for the evacuation of matter, and still later, 
they afford the readiest outlet to matter and sloughs. At this advanced 
period, however, the incisions must be made sufficiently deep to reach 
the whole of the infiltrated and gangrenous structures ; otherwise they 
cannot fulfil the important indications for which they are employed. 
Fomentations, in the first instance, and afterwards poultices, should be 
applied over the part. The patient should be watched, until all bleed- 
ing has ceased, as it may be necessary to resort to some proceeding, 
such as elevation of the limb, or slight pressure for some time, to prevent 
the hemorrhage from becoming excessive and injurious. 

The general strength requires to be kept up by generous diet, wine 



72 ERYSIPELAS. 

and other suitable means, during the severe trial to which it is subjected 
under the process of suppuration and granulation. 

In (edematous Erysipelas the constitutional treatment, in the first in- 
stance, consists in promoting a healthy condition of the secretions, by 
the employment of mild aperients with suitable regimen, and subsequently 
in improving the general health and strength, by the use of a light, nu- 
tritious diet, and by all the means suitable and available in the circum- 
stances. In most instances, as the case progresses, quinine will be in- 
dicated. The local treatment consists of rest, elevation of the affected 
part, warm fomentations, small punctures to allow the escape of serous 
effusion, and, at a not very advanced stage of the disease, support by 
means of bandages. 

In bilious Erysipelas, if the head be not severely affected, and the 
disease unattended with much pain or tenderness at the epigastrium, an 
emetic given at the commencement of the attack is usually of service ; 
after the operation of which a smart dose of calomel, followed by smart 
purgatives and diaphoretics is of great benefit. The subsequent consti- 
tutional treatment must be regulated according to the character of the 
disease, the states of general and local vascular action, and the condition 
of the vital powers. If there be much tenderness of the epigastric or 
hypochondriac regions, together with nausea or vomiting, local depletion 
in the vicinity, and afterwards blisters or sinapisms, are of essential ser- 
vice. Little local treatment is required beyond rest, and an attitude 
favourable to venous return ; the local, as well as the constitutional 
symptoms, being chiefly combated by internal remedies. 



73 



CHAPTER III. 

WOUNDS. 

The term wound, in the language of surgery, signifies a recent solu- 
tion of continuity in the living structures induced by some mechanical 
cause. 

Classification of Wounds. — Of the various divisions which have been 
made, an important one is the following, viz. ; — wounds of the head, 
neck, thorax, abdomen, and extremities. The peculiarities of symptoms, 
dangers, results and treatment depending on situation, will be mentioned 
in other parts of this work, where the affections of the particular regions 
are described ; but, in the present chapter, we shall adopt the classifica- 
tion into incised, lacerated, contused, punctured, gunshot, and poisoned. 

Various modes of healing. — The various modes in which wounds heal, 
may be enumerated as the processes of adhesion, granulation, and 
incrustation. 

1. Adhesion — union by adhesion — union by adhesive inflammation, 
and union by the first intention, are the synonymes by which this mode 
of healing is referred to. For n description of this process, the reader 
is referred to the section on the results of inflammation, where, under 
the head of exudation of coagulable lymph, the opinions entertained 
regarding this mode of healing are mentioned. The conditions favour- 
able for this mode of healing are — clean surfaces, unimpaired vitality, 
entire cessation of bleeding, perfect coaptation, exclusion of air, light 
dressing, and only a very slight grade of the inflammatory process. The 
treatment for adhesion will be afterwards considered. 

2. Granulation is the mode of healing usually to be promoted when 
adhesion fails. The little conical eminences which form on the surfaces 
of suppurating wounds are named granulations, from their granular 
appearance, and serve for filling up the cavities and bringing together 
the edges of wounds, and uniting them by what is called the second 
intention. 

As the processes of granulation and cicatrization have been already 
fully described, and as the treatment will come to be afterwards con- 
sidered, it seems necessary in this place only to mention that this is the 
suitable, and indeed the only practicable mode of healing, when the 
wound is of such depth and extent that it is impossible to place or retain 
the surfaces in coaptation ; when apposition is prevented by the presence 
of coagulated blood, or other foreign matter, which cannot be removed ; 
and also when, in consequence of prolonged exposure to the atmosphere, 
or of any other cause, such as contusion, the inflammatory process has 
been made to reach the suppurative grade. 



74 WOUNDS. 






3. The incrusting or " modelling" process, better known by the fami- 
liar, though less euphonious name of " scabbing," is best adapted for 
wounds presenting a superficial denuded surface, perhaps of considerable 
extent, but of little depth. It comes into operation when, there not 
being enough of inflammation to induce suppuration and granulation, or 
when, the vascular action of these processes having greatly subsided, a 
crust is formed on the surface of the wound by the drying, in the former 
case of coagulated blood or fibrin, and in the latter of fibrin and pus 
commingled. The crust may also be formed artificially, its use being to 
exclude atmospheric air, protection from the stimulus of which is essen- 
tial to this process. Beneath this covering, new matter is added on the 
surface of the wound, raising its level, if depressed, and skinning it over 
when nearly on a plane with the surrounding integument ; but the exact 
steps of the process are not fully ascertained. There is no suppuration, 
but merely a little serous discharge, oozing from beneath the edges of 
the crust. The cicatrix, when at last exposed, on detachment of that 
temporary covering, is more uniform, more similar to the original parts, 
and less liable to contraction, than a cicatrix obtained in any other way. 
If the inflammatory action increase during the process, suppuration 
ensues, and pus accumulates under the crust, raising it up and causing 
painful tension, and thus suspending, for the time at least, farther 
advance of the modelling process. Wounds heal very readily by this 
mode in the inferior animals, there being in them much less inflamma- 
tory tendency than in man. This mode of healing is most suitable for 
superficial wounds exposing a single surface, to which none other can be 
applied, provided there is no contusion of tissue, and little likelihood of 
inflammation. In deep wounds of uncomplicated character, the sides of 
which can be approximated, adhesion is more applicable and certain ; 
while in a deep wound, attended with loss of substance, so that coapta- 
tion is prevented, or in one of any form accompanied with much contu- 
sion, which must be followed by considerable inflammation, granulation 
offers the most available cure. 

The crust, if not naturally formed, may be supplied artificially by 
covering the surface with lint, which soon becomes soaked with the 
oozing blood, and on drying, hardens into a strong, well-adapted cover- 
ing ; or the crust may be furnished by gently pencilling the surface 
with nitrate of silver, which coagulates the secretion. A piece of gold- 
beater's skin should be applied over, and for a short distance around, 
the thin pellicle thus formed by the lunar caustic, to prevent its prema- 
ture cracking and detachment. Or, the crust may be formed, as Pro- 
fessor Miller recommends, by using a " thick semifluid solution of gum 
tragacanth," which is laid uniformly over the surface, where it soon 
dries, forming an unirritating, transparent, and effectual covering from 
the atmosphere, which covering can easily be repaired at any part when 
necessary, and which, should undue vascular action set in, is softened and 
set loose by the discharge to which the excess of inflammation gives 
rise. In the absence of the tragacanth solution, ordinary mucilage of 
gum acacia would form a similar, though probably a more brittle, and 
therefore inferior, pellicle. The part should be kept at rest, and, still 
further to assist in restraining local action, the antiphlogistic regimen 



WOUNDS. 75 

should be enjoined. When the modelling process 1 fails, the treatment 
for granulation is to be instituted. 

The permanent tissues of repair. — With regard to the repair of in- 
juries, it is known that in healing, the lesion of some textures is effaced 
by a reproduction of similar tissue, while the injury of other parts is 
repaired by the formation of a tissue less highly organized. Osseous 
and cellular tissue maybe reproduced, and minute nervous and vascular 
filaments are formed in the connecting substance. The development of 
blood-vessels for granulations, or for superficial deposits of lymph, adhe- 
sions, or the like, has been referred to in the chapter on Inflammation, 
and the views entertained by many regarding their formation, have 
been mentioned ; but in addition to the opinions already brought for- 
ward, it is proper to state, that, according to Mr. Paget, their develop- 
ment is always effected by the projection of culs de sac, commencing as 
mere dilatations, from a capillary arch passing close to the adventitious 
structure. These coecal diverticula, crowded with corpuscles, are pro- 
longed in a definite manner, towards and into the new tissue, so that 
they meet and adhere ; the double partition formed by apposition of 
their closed extremities gives way, and a new capillary arch, transmit- 
ting blood, is formed. Fibrous tissue is the medium of repair in wounds 
of cartilage, in the cut extremities of which, however, bone is sometimes 
deposited. Muscular fibre, when divided, is never reproduced, cellular 
and fibrous tissues forming the new bond of connexion, which gradually 
contracting, in most instances, draw the retracted ends of the muscle at 
last into pretty close apposition. Nerves, when divided, if their cut 
extremities be in contact, rapidly unite, but with some confusion of 
function, apparently from the precise continuity of individual fibres not 
being accurately restored. Even when a considerable interval has 
occurred between the ends, union has been effected, in the first place by 
material similar to that effused after wounds of other soft tissues ; but, 
in time, nerve-fibres become developed within this substance, probably 
by prolongation from the cut extremities, between which they form a 
communication, partially restoring the functions of the nerve. Not 
less, it is believed, than two years will suffice for the accomplishment of 
this process. There is " no example in which the nerve or ganglia cor- 
puscles have been reproduced." The repair of wounds differs somewhat 
according to their amount of exposure. 

In an open wound healing by granulation, all the parts become more 
or less matted together, but a subcutaneous incised wound, as practised 
on tendon, and properly treated, is much better regulated in its cure, 
and motion becomes free as before. The end of the tendon connected 
with the muscle retracts, and thus lies surrounded by healthy uninjured 
structures, quite removed from the site of the external wound. Liquor 
sanguinis is effused, and collects in greatest quantity, in that part of 
the sheath where there is most space, namely, that part vacated by the 
retracted tendon. .The serum is absorbed, and the fibrin coagulates. 
In a few hours, those parts of the wound which are in coaptation, in- 
cluding the opening in the skin, subjacent cellular tissue, and sheath of 

1 So named, it is said, because the new matter is added to the surface of the wounded 
part, so as' to restore its original formation or model. 



76 WOUNDS. 

tendon, have quite healed, but within the sheath, in the space between 
the ends of the tendon, fibrin exists in large quantity, chiefly derived 
from the muscular extremity of the tendon, which is the better nourished. 
By the usual process this becomes organized, and supplied with vessels. 
"About the tenth day," says Mr. Paget, " it is paler again, seemingly 
less vascular, and distinctly filamentous." These minute threads run 
on for some little distance, between those of both extremities of the 
original tendon, interlacing, and gaining a very firm connexion. In 
two or three weeks, the cure may be considered complete, continuity 
being quite restored, though still, for some little time, the new structure 
and its connexions are scarcely so strong as they ultimately become. 

They equal, in this respect, at least, any other part of the tendon, 
and, indeed, become quite undistinguishable from it. The cicatrix, 
after a wound, progressively improves in texture ; new cuticle, or a 
structure identical with it is formed ; but in the fibro-cellular tissue 
beneath, which occupies the place of the dermis, papillse, when formed 
at all, are few in number, and imperfectly developed. After the lapse 
of several months, occasionally of more than a year, elastic tissue, 
similar to that of the original integument, but in very sparing quantity, 
is sometimes discovered. 

INCISED WOUNDS. 

Incised wounds are such as are inflicted with a sharp cutting instru- 
ment. The form of wound presents regular and smooth-cut surfaces, 
and is consequently best adapted for healing by adhesion. The prin- 
cipal danger is from primary hemorrhage, which is greater in this kind 
of wound than in any other. 

The treatment of wounds. — The treatment of wounds varies accord- 
ing to their nature, and the mode of healing desired. In this depart- 
ment of practical surgery, a great and salutary revolution has been 
effected within the last seventy or eighty years. This change had, for 
many years before the period above mentioned, been occasionally advo- 
cated by individuals, whose efforts, though at the time isolated, and 
apparently little appreciated, no doubt tended to the introduction of a 
more enlightened system. Thus Paracelsus, who flourished from 1493 
to 1541, and who was after Hippocrates, the first who advocated simplicity 
in the treatment of wounds, plainly asserted, that, in the healing of inju- 
ries, nature is supreme, and that the office of the surgeon is merely to 
protect the vis medicatrix Naturce from hindrance or interruption. In 
1542, the application of water-dressing to wounds was recommended in 
a paper by Blondus, published at Venice. But, probably, the first 
occasion, on which public attention was at all aroused, was by the cures, 
then deemed wonderful, accomplished at the siege of Metz, in the year 
1553, by an empiric named Doublet, who employed linen dipped in 
pure water. In his practice its value was supposed to depend on cer- 
tain charms and incantations pronounced over it. Shortly afterwards, 
Pare', the father of French surgery, adopted the water-dressing without 
the mummeries of incantation. Writers followed at intervals. The 
French military surgeons, Barons Percy and Larrey, in their cam- 
paigns, also proved its value. The late Dr. Macartney, in Ireland, 



WOUNDS. 77 

ardently inculcated the use of water-dressing, and, to his successful 
exertions, much of the general adoption of that method of treatment is 
attributable. Very much is due on the same account in Great Britain 
to the late Mr. Liston, who, in his writings and practice, very strongly 
inculcated simplicity in every department of surgical practice : while 
eminent surgeons, yet alive, might be cited, who have contributed not 
a little towards obtaining for the simple and cleanly water-dressing, its 
present universal estimation. Even when adhesion is not desired, or 
attainable, the same application used warm, has, in the practice of 
very many, superseded the employment of the poultice. 

The treatment for adhesion — with reference, chiefly, to incised 
wounds, comprehends four important indications, namely, to arrest 
hemorrhage — to remove foreign matter — to effect and maintain coapta- 
tion — and to guard against excess of vascular action. 

The first indication is fulfilled, by aspersion of cold water, if mere 
oozing exists ; or, by the ligature, when a distinct artery is seen pour- 
ing forth its contents. The ligatures, one end of each having been cut 
off near the noose, are brought out between the lips of the wound, by 
the shortest route ; and if numerous, are arranged without entanglement 
into one or more bundles. These should, when otherwise convenient, 
leave the wound at its most dependent part ; so that the slight purulent 
secretion, which is pretty certain to occur in their track, may find the 
most direct and easy exit, and, by at once escaping, not interfere me- 
chanically with the process of adhesion in other parts of the wound. 
In amputations of the extremities, they are usually brought out at the 
angles of commissure between the flaps. The method of cutting off 
both ends of the ligature, and leaving only the knot, is now restricted, 
by almost all surgical authorities, to those cases in which the wound 
has no chance of uniting by the first intention. 

The second indication, which is to remove all foreign matter, includ- 
ing coagulated blood, should be attended to as soon as active bleeding 
has been suppressed. Were its fulfilment neglected, adhesion would in 
consequence be prevented. 

All oozing having been completely arrested, foreign matter removed, 
and the surface of the wound having taken on a glazed appearance ; — 
the third indication, — namely, to effect and maintain coaptation, should 
next be proceeded with. Such are the conditions which render coapta- 
tion advisable ; and with regard to the means employed for effecting it, 
they are position, plaster, sutures, when necessary, and, in some parti- 
cular circumstances, carefully adapted pressure. 

The position should be such as will best relieve tension of the muscles 
and integuments, and obviate venous congestion. A greater amount of 
relaxation is necessary in some wounds than in others. As muscles 
are the principal agents in causing retraction, and in preventing easy 
coaptation, the general rule is to put the limb or part into the position 
that would be given to it by the natural contraction of the wounded 
muscle. "When muscular fibres are cut transversely, there is much 
greater retraction, and consequently more necessity for the observance 
of a position that will secure relaxation, than when the wound runs 
parallel to, or between them, in which case relaxation might be carried 



78 WOUNDS. 

too far, by making the sides of the wound bulge loosely, and thus pre- 
venting accurate coaptation. In -such cases, the parts should be laid so 
as sufficiently to relieve tension, without permitting undue laxity. In 
amputation wounds of the limbs, where little relaxation is necessary, 
more than is already present, elevation, to such a degree as to prevent 
congestion, is the chief point of consequence with regard to position. 

Of retentive appliances, plaster is one of the most generally useful ; 
and of the various kinds of plaster, the best, though unfortunately also 
the most expensive, is that which was introduced into practice by Mr. 
Liston, and known by the name of isinglass plaster. It consists of 
gauze or silk, which, being stretched out, is frequently coated with a 
film of isinglass, until the adhesive layer be of the requisite thickness ; 
after which the other side is turned up and varnished with boiled oil. 
Its advantages are these, — the isinglass is perfectly non-irritating to 
the sound skin or its cut margins ; the oiled gauze is transparent, and 
accordingly does not conceal the state of matters below ; it is very easily 
applied, having only to be moistened with warm water ; it soon dries, 
becoming firmly adherent ; and the impervious nature of its varnished 
tissue prevents any moisture from the outside detaching it. When the 
wound is discharging, the plaster becomes loosened immediately over 
the edges, and for a little way beyond ; but this is really advantageous, 
as it favours free escape of secretion from between the lips of the 
wound ; and the loose, central portion stretching a little, allows room 
for the slight tumefaction which generally exists in some degree, when 
any discharge is being poured forth. On the other hand, cheapness is 
the sole recommendation of the common plaster, composed of emplas- 
trum plumbi, with resin added to make it sufficiently adhesive. From 
the nature of the latter ingredient, this plaster is irritating to the skin, 
and so favours inflammation and erysipelas. It does not adhere firmly 
when the skin is at all moist ; the calico on which it is spread being opaque, 
hides from inspection the parts beneath ; and when any ill-conditioned 
foetid pus comes from the wound, the plaster, if carelessly prepared, 
becomes blackened by the formation of sulphuret of lead, which smears 
the parts beneath; in the removal of which layer, as cleanliness de- 
mands, more washing and sponging are required than can be beneficial 
to the delicate margins of the wound. By slow boiling, however, for 
double the usual time, plaster may be made pretty adhesive without the 
addition of the irritative resin. 

The strips of plaster, varying in breadth according to the size of the 
lesion, are applied at intervals about as wide as the strips, while the 
assistant carefully holds the parts in the most favourable position for 
coaptation, and gently presses the cut surfaces and edges into apposi- 
tion. The intervals left, between the strips of plaster permit the escape 
of any secretion of serum or of pus, if afterwards formed ; and, it is in 
these intervals that sutures and the extremities of ligatures are, when 
employed, to be placed. The slips should be long, so as not merely to 
hold the edges in contact, but, by their adhesion to an extensive sur- 
face, to keep the parts well together. In longitudinal wounds of the 
extremities, however, they should not be so long as completely to en- 
circle the limb, as they would then constrict it, prove hurtful and pro- 



WOUNDS. 79 

vocative of inflammation and oedema, by obstructing venous return, and 
by rudely opposing the slight swelling which takes place in every large 
wound, even although adhesion be attained. 

Instead of isinglass plaster, strips of linen dipped in, or spread with 
collodion, have lately been employed. This substance, made by dis- 
solving gun-cotton in ether till the solution be of a syrupy consistence, 
dries very rapidly when spread out, in consequence of the evaporation 
of the solvent ; and in so doing, it contracts and tightens, leaving a 
transparent and colourless layer which adheres very firmly to the skin, 
and is unaffected by and impervious to any of the ordinary fluids natu- 
rally or artificially present about a wound. To procure its thorough 
adhesion, the skin must be quite dry at the moment of application. In 
cutaneous wounds, after the strips are dry and adherent, if there be no 
oozing of serum from the cut, a little collodion may be smeared in the 
intervals over the margins, by which means the edges will be preserved 
in contact, and protected from atmospheric irritation. The collodion 
may be tinted any colour, and it is worthy of remembrance, when large 
quantities of it are used, that it is highly inflammable, and that the dry sub- 
stance left by the evaporation of the ether, is quite as combustible as the 
gun-cotton before its solution, except that its now more compact and solid 
form renders combustion or explosion less rapid than in its original 
fleecy state. A substance closely resembling collodion in its properties 
and capabilities of application is prepared by dissolving certain propor- 
tions of gutta percha and caoutchouc in chloroform, and is used in pre- 
cisely the same manner. A third substitute for the isinglass and com- 
mon adhesive plaster has lately been employed. It consists of a thick, 
semifluid solution of gum-lac in alcohol, which may be prepared and 
kept in a wide-mouthed bottle with a closely-fitting cork. It is more 
economical than collodion, it is employed in the same manner, and is 
represented as being quite as efficient. It has, along with the gutta 
percha solution, the disadvantage of not being like collodion altogether 
colourless ; but it is said to possess, over both these preparations, this 
advantage, that moderate moisture does not prevent its adherence. All 
of these solutions, when applied to a raw surface, excite momentary 
smarting. 

Sutures, the next of the retentive apparatus, should not be employed, 
when it is possible to maintain steady apposition without them. During 
the first day or two, and before they have cut their way by ulceration 
through the skin, they certainly act more powerfully than plasters in 
maintaining coaptation, — one of the essentials for obtaining adhesion ; 
but they also irritate much more, and, if not speedily removed, excite, 
at least in their immediate vicinity, sufficient inflammation to lead to 
ulceration, preparatory to their spontaneous extrusion ; and the vascular 
action thus set up in one part of a wound, may extend so far as mate- 
rially to interfere with or prevent adhesion. Even under the most 
favourable circumstances, a slight suppuration seldom fails to follow in 
the track of each stitch ; and though, when the action stops here, the 
general healing of the wound may not be retarded, still the greater 
marking of the cicatrix, at each of these points, is an additional reason 
for avoiding their employment when possible, especially on exposed 



80 



WOUNDS. 




Fig. 16. 



15. parts. Sutures, then, are to be employed when there is 
difficulty in keeping the parts satisfactorily in contact by 
means of plasters ; but they should be as " few and far 
between" as consists with the attainment of their immediate 
object. They are introduced before the plasters are ap- 
plied; and on each side, but not over them, the strips of 
the latter should be placed. For deep wounds, and for 
those of irregularly shaped parts, the interrupted stitch is 
usually employed (Fig. 15); though, for the former class, the 
quilled suture is sometimes recommended; and for wounds in 
some situations, as will be explained in a future chapter, the 
twisted suture (Fig. 16) is the best for maintaining coaptation. 
The sutures should, in all instances, be removed as soon 
as it can be done without endangering the separation of the 
parts. If the structures be lax and easily kept together, 
they may be cut and removed at a very early period ; as 
soon, indeed, as the plasters have become dry and strongly adherent ; 
but, if there be tension in the lips of the wound, the whole, or some 
of the stitches, must be allowed to remain until the 
parts have become somewhat moulded to their new 
relations, and partially adherent. Again, if severe 
inflammation attack the wound, the sutures must be 
snapped and withdrawn, as their presence would only 
increase the mischief: — they would soon be set free 
by ulceration, but before this was accomplished, the 
undue constriction which they must have exerted on 
the tumefying wound, would stimulate the local action 
and aggravate the pain. 

Instead of the suture, M. Vidal employs a little spring forceps, about 
an inch and a half in length, to maintain coaptation. Its points are so 
far blunt, that, though they take hold of the skin, they pierce no more 
than the cuticle at most. It excites little or no irritation, and, when 
removed, leaves no mark. Another and smaller forceps, on a similar 
principle, but only about three-quarters of an inch long, is also employed 
in Paris. In venereal cases, in which circumcision is there frequently 
performed, the glans penis is surrounded with, as it were, a corona of 
these forcipes, the points of which keep the cut margins of the delicate 
skin and mucous membrane in most intimate contact, and the wound 
speedily heals with a cicatrix scarcely perceptible. 

In many, indeed, in most wounds, no other retentive apparatus than 
suture and plaster need be employed ; but in certain cases, when the 
wound is very deep, and its sides exceedingly loose, — conditions occa- 
sionally coexistent in persons of flabby fibre, and which favour the accu- 
mulation of secretions between the parted sides, — it may then be advi- 
sable to surround the wounded part with a turn or two of a bandage ; 
under which, but not over the mouth of the wound, a soft compress may 
sometimes be placed with advantage. The roller, at this early stage, 
must, however, be applied very lightly ; so that it shall merely assist 
in giving support, and in preserving apposition of every part, deep as 
well as superficial ; and operate more as a precautionary measure to 




WOUNDS. 81 

prevent displacement during any irregular muscular twitching, than as 
an immediate means of retention. Gentle support — not actual and in- 
jurious pressure — is wanted ; and the better to avoid this evil, it is well 
to damp the bandage previous to application ; for the dry fibre soon im- 
bibes moisture from the integument or the wound, and, in so doing, 
grows thicker and shorter, so as ultimately to become much tighter than 
when applied, or than was intended. 

The retentive apparatus having been thus applied, the wounded part 
is to be laid in a suitable position, combining relaxation and elevation. 
The latter is the point chiefly to be attended to after amputation ; 
and, for this purpose, the stump or other part is laid on a soft pillow, 
or any convenient rest, over which, for the sake of cleanliness, is spread 
a piece of oilcloth, or of thin sheet gutta percha, in order to prevent the 
parts beneath being soaked with any discharge. Along the margins of 
the wound, when large, a single strip of soft linen is placed, and kept 
moist with cold water; but in smaller and more sheltered injuries, this 
may be omitted. When the wounded part lies beneath the bedclothes, 
their pressure and heating effect must be prevented by a suitable cradle. 

All that now for some time requires to be done, is merely to keep the 
parts clean, wiping away any fluid secretion from the neighbourhood of 
the wound, but never actually touching its raw and tender margins. 
These matters being attended to, the part is to be kept otherwise, as far 
as possible, at perfect rest. 

Supposing all to go on well, the stitches, if such ha\e been employed, 
are removed at the proper time, as before explained ; but the plasters 
may possibly, in a large wound, require occasional renewal, owing to 
the fluid secretion trickling down and loosening their dependent extre- 
mities, or from their becoming unduly loose as the process of adhesion 
goes on, and the edges spontaneously approximate more perfectly. When, 
from any of these causes, it becomes necessary to change the plasters, 
they should be seized by both their extremities, and raised from each 
end towards the centre, which overlies the line of wound, and from this 
lastly they are with gentleness to be lifted. If, on the contrary, the 
strip were seized at one end, and pulled off along its whole course 
towards the other, it is obvious that after passing the central part, it 
would, if at all adherent, be apt to tear away the edge of the wound 
covered by its last half, from that margin to which its first raised por- 
tion had been applied. In renewing plasters, no more than one or two 
of the old strips, however loosely adherent, should be removed at once, 
before supplying their place with new pieces ; but as each slip is taken 
away, the vacancy is to be filled up before detaching another. This 
precaution is necessary, because if all the strips were removed at once, 
the wound, being unsupported, might fall open, and tender adhesions — 
the work of several days — be in an instant destroyed. Any necessary 
moving of the wounded part, whether for correcting malposition, clean- 
ing the support on which it rests, or applying fresh plasters, must be 
conducted with great care and gentleness. 

When ligatures have been employed, some of them will probably be 
loose by the end of ten days. Accordingly, about the expiration of that 
period, each ligature, except that on the main artery, which should be 

6 



82 WOUNDS. 






left undisturbed for at least a week longer, may be carefully isolated 
from the others, and gently pulled by the fingers or forceps. If loose, 
it will come away immediately ; but if the slightest resistance be felt, 
no force must, on any account, be used to withdraw it ; a few days lon- 
ger being allowed to elapse before it be again tried. The utmost gen- 
tleness is to be observed in this proceeding, lest the ligature should be 
drawn away before perfect occlusion of the vessel has taken place ; but 
with this precaution, it is better to try the ligatures, and remove them 
when loose, as if left to themselves they might remain in the wound 
long after they were detached, and thus retard its complete healing. 

Perfect healing, after adhesion has progressed favourably for about a 
week, is often retarded by an oedematous swelling, the result of undue 
vascular relaxation. In these circumstances, a bandage is to be ap- 
plied, so as to give support, and exert a moderate degree of pressure. 
This, however, must neither be severe nor unequally disposed, because 
in either case it would excite irritation, and the swelling of oedema 
would soon give place to that of inflammation. 

It must always be remembered, that at any stage, however late, 
excess of vascular action may set in, and prevent the further progress 
of adhesion, or even destroy the union already effected. It is frequently 
induced by cumbersome dressings, officious sponging and rubbing of the 
wound, and by an over-stimulating diet. 

The fourth indication, which is to repress inflammatory action, is ful- 
filled, partly by the simple local treatment just detailed, and partly by 
treatment directed to the system in general. The strict antiphlogistic 
regimen should be enforced, all stimuli removed, and perfect rest, gene- 
ral as well as local, enjoined. The food must be small in quantity, 
unstimulating in character, and given pretty cold. In feeble persons, 
and in individuals at an advanced period of life, the antiphlogistic regi- 
men must, however, be instituted with great caution, and its effects 
closely watched ; but, regarding these and many other points, the sur- 
geon must be guided by the peculiar circumstances of each particular 
case. 

Treatment for Cfranulation. — Wounds may require to be treated for 
granulation, either when inflammation has proceeded too far in a case 
which it was first attempted to heal by adhesion, or when, from the 
beginning, it was evident that granulation was the most suitable mode 
of healing, whether owing to loss of substance preventing coaptation, or 
to extensive contusion, or to the presence of foreign matter which could 
not be removed ; all of which conditions are incompatible with the 
attainment of adhesion, on account of the active inflammation to which 
they give rise. 

In the former case, that, of a wound treated hitherto for adhesion, its 
edges become swollen, red, and painful. Swelling more deeply seated 
causes the margins to separate, and purulent matter is soon poured 
forth. The indication here is to repress inflammation ; in fulfilment of 
which, all sources of local irritation and general stimulation must be 
withdrawn. Sutures, if present, should be removed, and only a few 
strips of plaster left, to prevent any unnecessary gaping of the wound, 
and in many cases they also must be dispensed with. To the parts thus 



WOUNDS. 83 

relieved from every kind of local irritation, warm water-dressings are 
applied, or a light, soft, moist, and warm poultice, if that application 
be still employed. 

In the second case, where granulation is from the first considered to 
be the most available mode of cure, the treatment is essentially the 
same as that mentioned above. The part is elevated, and kept at per- 
fect rest : no sutures are employed, and only a few strips of plaster are 
used to connect the more loose portions of the wound. Cold water- 
dressing is applied till oozing of blood ceases ; it is then gradually 
changed to the tepid, and next to the warm dressing, as the vascular 
action rises, so as to soothe and relax the tumefying wound. When 
the inflammation proves so active as to threaten gangrene, it must be 
repressed by local bleeding, and if absolutely necessary, by general de- 
pletion, in addition to the antiphlogistic regimen, which, during this 
stage of acute inflammation, is to be adopted. 

In both cases the same point is now reached. Warm dressings are 
continued so long as inflammation remains active ; but as it subsides, 
the heat of the dressing is gradually lowered until it «be again merely 
tepid, or even cool. 

Under this treatment the surfaces, if matters go on favourably, be- 
come clean in a few days ; granulations spring up, and healing advances. 
The discharge which, during the height of the inflammation, had been 
very profuse, and far from laudable, now diminishes in quantity and 
improves in quality. In these circumstances, the wound, when superfi- 
cial and broad rather than narrow and deep, requires merely the treat- 
ment proper for an ordinary ulcer ; comprising the water-dressing, 
medicated, when necessary, with metallic salts, to stimulate indolent 
granulations, and the employment of carefully-adapted pressure by a 
bandage, when necessary to repress oedematous swelling. 

But if the wound be deep, without much loss of substance — in fact, 
such a case as would have healed by adhesion had not inflammation 
prevented — then, at this stage, when the surfaces are granulating well, 
and secreting little pus, they will, if placed in mutual contact, speedily 
cohere, affording a most satisfactory and rapid cure by secondary adhe- 
sion. Plasters are employed to retain the parts in apposition, and a 
bandage, lightly and uniformly applied, is in general necessary to give 
support. As absolute local rest is necessary for healing, any neigh- 
bouring joint, which interferes with this essential condition in the 
wound, must be prevented from exercising its natural functions, by a 
splint fastened with a few turns of a roller, or with a buckle bandage 
applied at two or more points, lightly, so that no oedema may ensue on 
the distal aspect, and arranged so that neither splint nor bandage shall 
compress the injured parts, or come in the way of the requisite 
dressings. Cleanliness is throughout attended to ; the actual edges of 
the wound are not touched, but from all around them the discharge is 
frequently wiped away with a small dossil of clean lint, tow, or rag, or 
indeed of anything clean, soft, and absorbent. A good sponge answers 
well when there is only one wound to dress, because it can then be fre- 
quently washed ; but, in hospital practice, it would come into contact 
with all kinds of sores, and would never be sufficiently well or often 



84 WOUNDS. 

cleansed after each time of its employment. On the other hand, the 
morsel of tow, being of small value, may be destroyed, and a fresh 
piece employed on each occasion. 

The constitutional treatment — which, during the height of the inflam- 
mation, comprised at least the antiphlogistic regimen, and sometimes 
also local or general bleeding, according to circumstances — consists 
now, while matters are going on favourably, in attention to the secre- 
tions, and avoiding, equally, undue stimulation or hurtful abstinence. 
In individuals of debilitated constitution, and even in persons previously 
of good health, when the wound is large, suppuration may continue pro- 
fuse, cicatrization proceed very slowly, and the secondary adhesion fail. 
Under these circumstances the diet must be full and nutritious, with a 
due allowance of stimuli. In severer cases this generous regimen must 
be farther assisted by the exhibition of medicinal tonics. Though the 
part itself must be kept at rest so that it may heal, yet it may be much 
benefited indirectly by appropriate general exercise, with the view of 
strengthening the system. 

LACERATED WOUNDS. 

Lacerated wounds are produced by a blunt body being driven into 
and through the textures, or by a moving body becoming attached to a 
part, and tearing it away. In both cases the edges are ragged and 
uneven, the parts being torn rather than cut ; in both there is considerable 
straining of the surrounding structures, and in the former an amount of 
contusion is inflicted by the body entering and passing through the tis- 
sues. This dragging and bruising of the parts weaken their vitality. 
From the depression of the nervous system in severe cases of this 
nature, there may be little pain. So much, indeed, is this the case, 
that an arm has been torn off by machinery, and yet the person has for 
some time experienced little or no pain. There is, in general, also but 
little hemorrhage, partly because the surface of the wound being irre- 
gular, the blood is very apt to adhere and become coagulated ; partly 
because the vitality of the vessel has been diminished by the straining. 
But the chief reasons why arteries bleed less when lacerated than when 
cut, are, that when torn the coats do not retract equally, the inner and 
middle coats contract and retract within the external tunic ; the external 
coat next retracts within the sheath to a less degree, and the sheath 
forms a conical cavity beyond the outer tunic. These conditions are 
obviously much more favourable for the arrest of hemorrhage than the 
uniformly retracted coats of a cut artery. Although the pain may 
often be slight at first, and although there may be little primary hemor- 
rhage, these wounds are ultimately much more dangerous than those of 
a simple incised character. They are very apt to be followed by severe 
inflammation ; and, if there be much bruising by sloughing, they are 
more liable to be followed by severe constitutional disturbance, and by 
tetanus ; and, if gangrene ensue, there is danger of secondary hemor- 
rhage on the separation of the slough. 

In the case of a purely lacerated wound, or when contusion, though 
present, is so only in a very slight degree, adhesion is possible, and 
ought to be attempted ; and if it should fail, from inflammation running 



WOUNDS. 85 

too high, the wound is still as much disposed for granulation as it would 
have been, had adhesion not been tried. Besides, a part of the lesion 
may adhere and remain united, even while granulation occurs in the 
remaining portions. 

The treatment of those wounds which are purely lacerated in their 
character, or at least attended with extremely slight contusion, is, with 
some modifications, the same as that already related as conducive to 
adhesion. Sutures should, if possible, be still more avoided than in 
simple incised wounds, and isinglass plaster chiefly trusted to for main- 
taining coaptation, so as to diminish, to the utmost, all sources of local 
irritation. Absolute rest of the part, and usually of the whole body also, 
is requisite. The water-dressing is applied cold or nearly cool, for the 
latter is usually more agreeable to the feelings of the patient. If the 
attainment of adhesion be peculiarly desirable, it may be necessary, in 
addition to the abstraction of all sources of local or general excitement, 
and the rigid observance of the antiphlogistic regimen, to take blood 
from the part, or even from the system, in order to keep the inflamma- 
tion within proper limits. Under this treatment many such wounds 
heal partially, if not altogether, by adhesion. Should, however, inflam- 
mation prove too active, a change should be made to the treatment for 
granulation. 

CONTUSED WOUNDS. 

Contused wounds are caused by very blunt bodies passing in a tear- 
ing manner through the tissues, inflicting in their passage a large 
amount of contusion and straining. They are, in general, merely lace- 
rated wounds, accompanied by much contusion ; but this complication 
renders them more dangerous, more tedious to cure, and productive of 
greater deformity. When the bruising is very decided and instantaneous, 
there is usually not much pain. This circumstance, however, is merely 
a symptom of the contusion being very severe ; for if it be but slight, 
the pain may be pretty acute. The primary hemorrhage is seldom con- 
siderable ; but bleeding may occur to a dangerous extent on the separa- 
tion of sloughs. In severe cases, there is considerable collapse, and 
reaction is proportionately violent. Excessive inflammation attacks the 
wound, and gangrene not unfrequently occurs, sometimes to a large 
extent, especially in vitiated constitutions. A large sore follows the 
loss of substance, suppuration is profuse, and may be so prolonged as to 
induce hectic fever. Or pyaemia may occur, and typhoid symptoms 
become developed. 

The treatment of wounds, in which the contused character prevails, is 
regulated with a view to granulation. The bleeding having ceased, 
foreign matters being removed, and the wound cleansed, the part should 
be placed in a position that combines relaxation with elevation, both 
these conditions being calculated to relieve the supervening local action. 
Sutures are useless, and the irritation caused by them would be injurious. 
Even plasters are unnecessary, except when the wound has a strong 
tendency to gape widely, or when, at some parts, the contusion having 
been slight, there may be some hope of partial adhesion, on coaptation 
being effected. Warmth is applied either by means of cloths dipped in 



86 WOUNDS. 

warm water, or by means of a soft, light poultice, in which the bruised 
part is imbedded. Neither application must be allowed to become dry 
or cold, but is to be renewed as frequently as may be requisite. 

When the inflammatory action runs high, depletion — local and gene- 
ral — may be necessary to repress its violence, and limit the consequent 
amount of sloughing. But this part of the treatment must always be 
conducted with the greatest caution ; remembering that ere long the 
system may be taxed to the utmost, in maintaining suppuration from an 
extensive surface, and which may, by long continuance, induce hectic 
fever before cicatrization be effected. 

During the progress of the inflammation, diffuse abscess occasionally 
occurs, and must be evacuated by free incisions. As the slough sepa- 
rates, the patient should be watched, lest secondary hemorrhage should 
occur ; and after the separation, the proper treatment instituted. The 
warmth of the applications should of course be reduced when the process 
of granulation commences, as the relaxing effects of the heat would then 
be injurious. Amputation may be necessary when there is very exten- 
sive crushing of the soft parts, or comminution of bones ; and also when 
the gangrene is very extensive, accompanied by proportionate constitu- 
tional disturbance. 

The constitutional treatment need scarcely be recapitulated. During 
collapse, if long persistent, stimuli may be required, yet should be given 
as sparingly as consists with the attainment of the object for which they 
are given, and not to such extent as to aggravate the subsequent reac- 
tion and its consequences. During the height of the inflammation, the 
antiphlogistic regimen should be adopted ; and, when necessary, local 
or general bloodletting, according to the violence of the action, but in 
every case with great caution. 

PUNCTURED WOUNDS. 

Punctured wounds are produced by the penetration of a narrow and 
pointed object into the tissues, — usually to a depth disproportionate to 
the small aperture of entrance. According as the point of the instru- 
ment is sharp or blunt, and its blade thin and flat, or thick and bulky, 
will the injury partake chiefly of the physical characters of an incised 
wound, or of those of the lacerated and contused varieties ; that is to 
say, the wound has some of the characters belonging to each of these 
three species, and according as one or other predominates, the lesion is 
more or less serious. Unless some very important organ has been in- 
jured, the shock is less marked in this than in some other kinds of 
wound ; but whenever the weapon has passed far and deeply into any 
tissues, the lesion must be considered of a serious character, more par- 
ticularly as it cannot at first be known what parts have suffered, and 
what have escaped. There may be at the time little primary hemor- 
rhage, although a considerable artery has been wounded, because of the 
form of the wound being unfavourable to the free exit of blood. In such 
a case, however, the blood is certain to break out speedily, and even 
although no large vessel be wounded, there is still the danger of secon- 
dary hemorrhage, if there has been bruising to an extent calculated to 
lead to inflammation and sloughing. Nerves likewise may be cut, torn, 



WOUNDS. 87 

or punctured, and consequently for this reason, as well as for others, 
tetanus is more to be dreaded in these wounds than almost in any of the 
other varieties. 

Very violent inflammation usually follows punctured wounds of any 
considerable depth ; not only on account of the mode of their infliction, 
but also because the blood, which oozes from the surface, does not meet 
with a ready exit, but remains coagulated, forming a layer of foreign 
matter, or becomes infiltrated into the soft tissues, chiefly the cellular. 
Inflammation is further favoured by the probable lodgment of extrane- 
ous bodies ; perhaps of a portion of clothing driven in before a blunt- 
pointed weapon, or of the sharp point of a more delicate instrument 
which has been broken off against a bone that resisted its farther pro- 
gress. Violent inflammation is pretty certain to follow punctured 
wounds of synovial and serous cavities, of dense fibrous structures, and 
of the scalp, in which latter situation it usually assumes the erysipelatous 
form. When of considerable depth, several layers of aponeurosis are 
generally traversed ; and these unyielding structures, by tightly con- 
fining the parts beneath and preventing their tumefaction as vascular 
action rises, aggravate the subsequent inflammation, while the matter, 
not finding sufficiently free vent, is very apt to burrow along the muscu- 
lar interspaces beneath the fasciae, and give rise to diffuse purulent 
infiltration of the cellular tissue. 

The treatment of punctured wounds varies according to the depth of 
injury, and the amount of accompanying contusion and laceration. 
When the wound is of small depth, attended with little or no bruising, 
and is free from foreign matter, adhesion is possible and should be pro- 
moted. Till oozing ceases from the external orifice, cold aspersion is 
to be practised. When no more blood issues, any little apposition re- 
quired by this form of wound is to be effected, and a piece of isinglass 
plaster placed over the opening, so as to cover it entirely, or with the 
exception of the most dependent point. The patient is to be kept quiet, 
and restricted to the antiphlogistic regimen. Under this treatment, 
most of these slight wounds heal ; but if the case be a little more severe, 
the cold water-dressing, or a cooling saturnine lotion may be applied ; 
still, however, retaining the morsel of plaster, so as to preserve the 
actual margins of the wound from irritation, and to prevent the liquid 
application from insinuating itself along its track. A single layer of 
moistened lint is employed, but without oiled silk above it, as the object 
is to encourage rapid evaporation, and procure its refrigerant effect. 

In more serious cases the treatment becomes, in a corresponding 
degree, complicated. Thus if hemorrhage takes place from a wounded 
vessel, which cannot be reached on account of its deep situation, and the 
narrowness of the wound — while pressure fails to arrest it, or, owing 
to the peculiar situation of the injury, cannot be employed — then 
the wound must be dilated by careful incision to the required extent, 
and in the safest direction, so as to permit the artery to be tied above 
and below the point of lesion. Dilatation may also be requisite, when 
foreign matter has lodged in the wound, the presence of which will be 
ascertained by learning the mode of infliction, by inspecting the weapon, 



88 WOUNDS. 

or, if necessary, by the gentle use of the probe. The foreign substance 
may then be removed by a forceps, or any convenient instrument. 

It was formerly the custom to dilate every punctured wound by tents 
and plugs. More recently simple incision was substituted with the hope 
of transforming the lesion into a mere incised wound, which, as has 
already been seen, is of a much more simple character. This indis- 
criminate use of the knife is now justly abandoned, and dilatation prac- 
tised at this early stage only with a view to permit the ligature of a 
bleeding vessel, or the removal of foreign bodies; and, at a later period, 
to effect evacuation of matter, and thus afford relief from tension. The 
wound being now free from extraneous substances, its edges are brought 
gently together, and cold water is applied till oozing ceases. Apposi- 
tion is then effected, and preserved by one or more slips of isinglass 
plaster ; and cool water-dressing applied to prevent undue vascular 
action. 

Subsequently, when pain, tension, and inflammation ensue, and prove 
severe, warm fomentations, medicated, if necessary, with opium, are 
applied to soothe and relax the parts. Adhesion not having taken place, 
the subsequent treatment is adapted for granulation. In cases still more 
severe, abstraction of blood from the parts around the wound, and from 
the system, may be necessary to limit the action and sympathetic dis- 
order of the constitution. When deep-seated inflammation occurs, par- 
ticularly when under dense fasciae, indicated by severe pain, diffuse 
swelling and hardness, then early and free incisions are demanded to 
relieve tension and afford free vent to matter. 

The constitutional treatment, which in punctured wounds frequently 
requires to be pretty active, is conducted on the same principles which 
have so often been referred to in pages immediately preceding, and 
therefore need not here be recapitulated. 

GUN-SHOT WOUNDS. 

Gun-shot wounds, the most frequent injuries in modern warfare, are 
inflicted by shot projected from pistol, musket, rifle, or cannon, by 
splinters of wood or stone, shattered by an impinging ball, and by frag- 
ments of iron, or other substance, scattered around on the explosion of 
shells. They present, according to the nature of the penetrating body, 
various degrees and combinations of contusion, laceration, and puncture. 

With regard to these injuries, there are many circumstances which 
require to be understood. A ball projected through the air, proceeds 
at first with great force and rapidity, nearly in a rectilineal direction ; 
and if it come, during this part of its course, in contact with any por- 
tion of the body, it either penetrates and lodges, or passes directly 
through, or carries the part away, according to the force and size of the 
shot. 

After a time, the ball describes a curve, called the parabola ; its velo- 
city diminishes, and it acquires a new motion of rotation on its own 
axis. In this stage, very slight obstacles deflect it from its course, 
and should it now impinge against the body, the ball, even though large, 
may not sweep away the opposing part, but merely be turned aside, roll- 
ing over the surface, and inflicting, in proportion to its remaining mo- 



WOUNDS. 89 

mentum, a dreadful amount of contusion. This is indicated by the cold, 
soft, and flaccid feeling of the part, and its diminished or destroyed sen- 
sation. Such is the explanation, as given by Larrey and modern mili- 
tary surgeons, of those cases of violent bruising of the soft parts, frac- 
ture of bones, and dangerous or instantaneously fatal concussion of 
internal organs, by large shot, frequently without laceration of the inte- 
guments, or the infliction in rapidly fatal cases, of any outward sign of 
injury. These accidents were formerly attributed to the " wind of the 
shot," caused by its passing with extreme velocity close to the body; 
but they are now with more accuracy referred, as above, to the actual 
contact of "spent balls." 

The aperture of entrance made by a ball, is much smaller than the 
aperture of exit ; and very generally, owing to the elasticity of the in- 
tegument, much smaller than the shot which actually entered, while its 
margins are inverted and uneven. The aperture of exit is larger ; its 
edges are everted, and more ragged than the former. When discharged, 
either at a very short or long distance from the body, a ball enters more 
roughly, and produces a more ragged wound than when it strikes in the 
middle of its range. At its entrance, and during the first part of its 
course through the tissues, its transit is chiefly characterized by contu- 
sion ; while farther on, and towards its exit, its effect is more purely 
laceration. In the former part, therefore, sloughing is more probable. 

In the stage of diminished momentum, the shot, if small, may also be 
deflected, when it impinges very obliquely upon the surface ; or, piercing 
the integument, it may proceed beneath it, sometimes along the trunk, 
or the hollow aspect of a limb during flexion, sometimes partially or 
completely round either ; or penetrating more deeply, it may enter the 
thoracic or abdominal cavities, and course around their interior circum- 
ference, without wounding the contained viscera. It is, in fact, deflected 
from its straight course, when the obstacles to its direct continuance are 
greater than to slight deviation. From these circumstances, it happens 
that the course of balls is very uncertain. A button, or other hard ap- 
pendage of the dress, and the common articles usually contained in the 
pockets, have frequently repelled, arrested, or deflected a ball, to the 
manifest preservation of life. Sometimes, on the other hand, these 
bodies are forced into the tissues before the bullet. 

After penetration, their course is not more certain. Bone, and softer 
structures, may alter their direction ; and the elasticity of the common 
integument often confines them after passing through denser structures. 

A bullet may lodge, or escape, after the most direct or the most 
devious route. It may lodge immediately beneath the integument, 
either at the point of entrance ; or after passing through towards the 
opposite aspect ; or after coursing on beneath the skin — its direction in 
this subcutaneous course being indicated by a discoloured mark, com- 
monly called a "weal." It may lodge in bone, in any of the soft 
tissues, in the interior cavities, in fact in any part, however distant from 
its point of entrance, after the most direct or the most circuitous and 
lengthened route. It may escape, by an opening directly opposite to 
the aperture of entrance, after passing directly through the part, or 
merely running round beneath the integument; or it may proceed 



90 WOUNDS. 

further in the latter course, escaping near the aperture of entrance, by 
which it may indeed emerge, so that only one opening is made, — -a cir- 
cumstance which might lead to the belief that the shot had lodged. 
Under one other condition the same may occur. Thus, sometimes, when 
the ball, possessing slight impetus, strikes a part of the body covered 
by dress, it may, if this be thin and tough, force a portion of it before 
itself into the wound, and that without tearing it off, so forming an in- 
volution, or cul de sac, in the interior of which the ball lies, and from 
which it drops accidentally, or is brought away by traction on the re- 
mainder of the cloth. In this case, where the wound lies beneath cloth- 
ing of unbroken continuity, it cannot of course be supposed that the 
ball has lodged, although there be but one aperture. A leaden bullet, 
impinging on a sharp edge of bone, may be divided, and a half pass on 
each side of the opposing bone, each portion emerging by a separate 
aperture ; or one part may escape and the other be detained. The ball 
may force a portion of clothing into the wound, and both lodge together; 
or, itself passing by, may lodge further on, or escape. 

Perhaps it is no bullet of lead or of iron which enters, but a frag- 
ment or splinter, dashed up by the striking of a shot in the neighbour- 
hood, or by the bursting of a shell. Or it may be neither metal, stone, 
nor wood which enters, but merely wadding, as may occur when the 
gun is fired at close quarters, and not loaded with any more solid pro- 
jectiles : for, at short distances, wadding may penetrate many layers of 
dress, carrying portions along with it, inflicting a ragged wound, and, 
when deep enough, almost invariably lodging. A single deep and very 
uneven wound may also be produced by an aggregation of small shot, 
ere they have proceeded far enough from the gun to have become widely 
separated. 

When there is more than mere contusion, the opening of entrance is 
of course always present, but that of exit is more inconstant. It may 
be wanting altogether, as when a bullet lodges ; or wanting, at least as 
a separate orifice, when the bullet emerges at the same aperture by 
which it entered, either after crossing beneath the integument, com- 
pletely around the limb, or when drawn out along with an untorn tubu- 
lar invagination of the dress. The opening may be single, by which 
the whole bullet, or only half of it, when split after entrance, has 
escaped ; or it may be double, when both portions of the bullet, split 
on a crest of bone, have emerged each by a separate wound of the 
integument. 

But two bullets may have entered by the same wound, and only one 
of them have escaped ; and though there may be one or more apertures 
of exit, yet these apertures may have been apertures of entrance to 
other balls which also have lodged. 

The amount of injury varies, of course, according to the parts 
wounded. Owing to the uncertainty regarding the course of the ball, 
it is impossible, at first, to say what these parts are ; and time alone 
can show what shall be the ultimate amount of destruction, after inflam- 
mation and sloughing to a greater or less extent have occurred. Large 
vessels may be wounded, while yet sometimes they marvellously escape 
division, as when a bullet passes between a large artery and its vein, 



WOUNDS. 



01 



lying together in close juxtaposition. In these cases, however, the ves- 
sels are generally so much bruised, as to slough or ulcerate during the 
coming inflammation, giving rise to secondary hemorrhage. Important 
nerves may narrowly escape, or be bruised and divided. Bone may be 
simply fractured, with or without wound of the integument ; yet still 
not without much contusion, favouring the occurrence of necrosis : or, 
it may be, extensively comminuted and splintered, or perforated, the 
aperture thus made being always, in the flat bones at least, considerably 
larger than the bullet : or, it may be the resisting body in which the 
ball lodges. Serous or synovial cavities, and mucous canals may be 
traversed, or merely entered, while the foreign body lodges. Vital 
or other important organs may be injured, but it by no means fol- 
lows that death shall be immediate, in even extensive lesion of some of 
these parts. 

Gun-shot wounds are very liable to be complicated in their progress 
by various affections. They are peculiarly apt to be followed by deep- 
seated inflammation, and purulent infiltration of cellular tissue. Necro- 
sis is a very common result of exposure or bruising of bone. 

The pain occasioned by a mere flesh-wound from fire-arms is usually 
not severe at first. There may be a momentary pang, but it is gene- 
rally more a sense of numbness and loss of power that are experienced. 
When, however, bones are fractured, and large nerves lacerated, severe 
pain is at once produced. Hemorrhage may not be great when no large 
vessel is divided, but when such is the case, bleeding may be copious. 
It is really as abundant — though perhaps it may not appear externally 
for some time, as after most other kinds of wounds, except the smooth 
incision ; and certainly much more so than after a simple laceration. 
The form of a gun-shot, as of a punctured wound, favours the easy sup- 
pression for a time of external hemorrhage, even when a large vessel, 
deep-seated, has been opened ; but here, after a period, blood will break 
out unexpectedly, or it may be pouring forth internally to a fatal 
extent. Secondary hemorrhage, also, is much to be dreaded, particu- 
larly when extensive sloughing, or sloughing phagedena, occurs — 
neither of which is very uncommon during unhealthy seasons, and in 
crowded military hospitals during time of war. 

The shock varies much in degree. There seems every reason to 
believe that the mental part of it, at least, is generally more severe in 
gun-shot, than in other wounds of equal extent. Owing to the extra- 
ordinary force and rapidity of the missiles, against which no guard can 
be raised, an injury thus inflicted is regarded with a greater degree 
of apprehension than others of a nature which can, to some extent, be 
foreseen and guarded against, and which, in a slighter degree, are more 
generally incurred. I refer to cuts, and stabs, those received in action 
being aggravated examples of what happens, on a much reduced scale 
indeed, but still very frequently, to all persons who employ sharp instru- 
ments of any sort. Some men certainly sustain very extensive gun-shot 
injury of the extremities, without being much depressed ; or are so only 
for a short time. But in others, undoubtedly brave, a comparatively 
slight wound of this nature is productive of the severest symptoms of 
shock. In this case, however, words of encouragement, together with 



92f 



WOUNDS. 



the exhibition, if necessary, of diffusible stimuli, soon rouse the patient 
from this chiefly mental depression. But when the symptoms of shock 
continue long and severe, notwithstanding the employment of the resto- 
ratives just indicated, it may with reason be concluded that there are 
ample grounds, of a physical character, for its long continuance ; and 
that, owing to the lesion of some important organ, the wound is in reality 
of a much more serious character than was at first imagined. 

In the treatment of gunshot wounds, the first indication is, to promote 
the departure of collapse when this is present to a serious degree, by 
encouraging language, and, when necessary, the administration of diffu- 
sible, or even more permanent stimuli. The latter, however, should for 
obvious prospective reasons be, when possible, avoided. If the pain at 
this early period be excessive, anodyne fomentations are advisable. 

When the shock has by these means worn off, the subsequent treatment 
is to be regulated by a consideration of the nature of the wound — of the 
part injured, and the extent and kind of lesion — of the present and pre- 
vious sanatory condition of the patient — and of the means of treatment 
at command. 

Thus, when a limb has been rudely carried away, leaving the remain- 
ing parts very much contused and ragged, conditions which would neces- 
sarily insure the occurrence of extensive gangrene, great constitutional 
disturbance, an useless stump, and probably also hectic fever from pro- 
fuse discharge, and tardy cicatrization ; — when there is extensive contu- 
sion, amounting almost to disorganization of the soft tissues of a limb, 
either with or without fracture of bone ;- — when there is extensive bruising, 
laceration, or removal of the soft tissues, especially of the chief vessels 
and nerves ; — when there is much comminution, or bad compound fracture 
of the shafts of bone, particularly of the femur ; — when the joint-ends 
of bones are shattered, and large articulations laid open, such as the 
knee, ankle, or hip-joint — then, in all these cases, unless there be also 
some other and decided mortal injury, amputation is generally considered 
requisite, either actually to save life, or to protect the system from very 
great risk and suffering, which if at last surmounted, could only result in 
affording a very bad natural stump, or in the preservation of a useless limb. 

In military practice, primary amputation, performed during the few 
hours between the departure of collapse and the supervening of inflam- 
mation and symptomatic fever, has been found far more successful than 
a similar operation performed at a later period, after the system has 
suffered from inflammation, irritation, and it may be, typhoid symptoms, 
extensive gangrene, and probably hectic fever. During the more violent 
stages of most of these complications, no operation could well be practised, 
but would require to be further delayed, until the system lapse into a 
more quiescent state. In, campaigns also, it is, in order to save life, 
frequently necessary to amputate a limb at once, which, with the more 
ample conveniences for treatment enjoyed in civil practice, might possi- 
bly have been saved : but which, owing to the turmoil of the camp, the 
jolting of the march, the possible deficiency of suitable apparatus, and 
the crowded condition of military hospitals during war, where the num- 
bers prevent any extraordinary attention from being paid to a single case, 
would certainly, if not removed, be attended with fatal consequences. 



WOUNDS. 93 

It must be remembered that in the upper extremity, although bones 
may be badly fractured, or joints opened, with or without shattering of 
the articular extremities of the bones, yet a useful limb may be saved. 
In the former case, when there is merely a simple laceration, adhesion 
may possibly be attained ; and in the latter, excision of the joint-ends 
is preferable to amputation of the limb. The last remark applies also 
to open fracture of the neck of the thigh-bone, accompanied with bruising, 
when neither the trochanter nor the pelvis has shared in the comminution. 

These injuries, converted by amputation into clean incised wounds, to 
be healed by adhesion or granulation, being now kept out of view, other 
cases of a less immediately dangerous character come to be considered. 

In addition to promoting departure of collapse, the principal indica- 
tions are, — to arrest hemorrhage, — to remove foreign matter, whether 
balls, fragments of metal, clothing, stone, wool, or earth, as well as any 
portions of bone, which have become so detached as to afford no chance 
of reuniting, but would, if left, become necrosed ; — to limit by local and 
general means the coming inflammation, and its probable sequence, gan- 
grene, which would entail loss of parts and serious constitutional dis- 
turbance ; — to obviate the accidental complications ; — to promote heal- 
ing, and support the system under suppuration ; to remove the limb 
under certain circumstances by amputation, when extensive or extend- 
ing gangrene occurs, or suppuration is excessive, and hectic fever other- 
wise intractable, this being called secondary amputation ; and to perform 
another and second amputation, when the stump obtained by the pri- 
mary, or secondary operation has been destroyed, or much injured by 
further gangrene or sloughing phagedsena, with consequent protrusion, 
and exfoliation of the bone. 

The wounds inflicted by fire-arms, which are of an open, lacerated, or 
contused character, being treated exactly as similar injuries produced 
in any other manner, the following observations are chiefly directed to 
those lesions most characteristic of the passage of a comparatively small 
body into or through the living structures, namely, those wounds which, 
in addition to contusion and laceration, have a punctured or tubular 
character. 

The first indication, namely, to arrest hemorrhage, may be accom- 
plished by cold, and slight pressure, when there is mere oozing. But 
whenever an important arterial trunk has been wounded, nothing but 
ligature of the vessel, above and below the point of lesion, can be trusted 
to. In order to reach the artery, and permit the application of liga- 
tures, the wound may require to be dilated by incision, perhaps in a 
very free manner ; — a practice which is also necessary under two other 
conditions, namely, when foreign matter has lodged and cannot be re- 
moved without enlargement of its tract, or when matter forms and is 
not freely discharged. Pressure is usually inefficient to stay the bleed- 
ing, and could seldom be applied with the requisite nicety, or without 
resting injuriously on the neighbouring parts, some of which, as well as 
a portion of the artery itself, are pretty certain to slough. The second 
indication, — removal of foreign matter of whatever nature, — may some- 
times be effected by the finger or forceps without enlargement of the 
wound, sometimes by slight dilatation, and occasionally by a mere cuta- 



94 WOUNDS. 

neous incision, when the ball is felt resting beneath the integument. It 
is very important to remove all extraneous substances, when possible, 
without great meddling and cutting, because their presence aggravates 
the coming inflammation, and in this manner retards the cure. But 
when the foreign matter is deeply lodged among important parts, where 
dilatation could not be practised without danger, or when it is firmly 
lodged in or between bones, whence it could not be extracted without 
further crushing or fracture, it must be allowed to remain until suppu- 
ration has ensued. Then the part being relaxed, and the channel 
widened, it may in general be withdrawn with facility. From some 
situations, however, bullets cannot be even then removed without very 
extensive incision. It is sometimes difficult, if not impossible, to ascer- 
tain with certainty whether or not foreign matter is present. In some 
circumstances, indeed, as when it is known that there was only one dis- 
charge of a piece of fire-arms, loaded with a single bullet, then the num- 
ber and situation of the apertures will afford pretty strong presumptive 
proof of the ball having lodged or escaped, while the part of the body 
injured, and its distance from the weapon, may indicate whether or not 
portions of clothing or wadding may also have entered. But, from 
former remarks, it is evident that in action, where numberless missiles 
are flying about in all directions, no such inference can be drawn 
from simple inspection of the wound. Accordingly, the part is 
placed in the same attitude in which it received the ball, as by 
the position, the tract of wound, through successive layers of struc- 
tures, is made more directly continuous, and its exact direction may be 
more easily guessed. The finger or probe is now to be employed, 
gently, but with decision, so as to ascertain the presence of foreign 
matter. Probing is much better tolerated at this early period than 
on any subsequent occasion. On the extremities, this operation may 
be performed with some degree of freedom ; but when the ball has 
pierced the parietes, and entered either of the three great cavities, no 
exploratory proceeding is justifiable. If it be felt imbedded in the sub- 
stance of the walls, or immediately within them, it should, of course, be 
removed ; but if not at once discovered, no further manipulation is proper. 
A contrary proceeding might, indeed, at the expense of much injury, 
satisfy curiosity, yet without in the slightest degree affording oppor- 
tunity of adopting any important alteration of treatment. 

Smooth and rounded balls, when they cannot be removed at first, 
sometimes remain imbedded for a long series of years, enclosed in a 
cyst or capsule, seemingly of condensed cellular tissue, or in the dilata- 
tion or cul-de-sac of a long, winding, and narrow sinus, so as to be pro- 
ductive of little inconvenience or uneasiness, except during atmospheric 
changes, much exercise, or general ill-health. In general, they at last 
come slowly to the surface, when they may be removed, or by creating 
an unusual amount of discomfort the patient is ultimately induced to 
submit to a deep operation for their removal. Rough and angular frag- 
ments of iron, or of detached bone, create greater mechanical irritation, 
lead to more active inflammation and suppuration, and require more 
speedy extrusion. The third indication, — to limit inflammation and its 
consequences, — is effected locally by rest, elevation, and relaxation of the 



WOUNDS. 95 

part ; by careful adjustment ; and by cold water-dressing, under the 
use of which, Mr. Guthrie has shown that the sloughing consequent on 
gun-shot wounds is much less than under the old treatment by heat and 
poultice. The cold applications are continued for a considerable time, 
and when the inflammation has become very high, they are gradually 
changed for the tepid, and finally for the warm dressing, which by its 
relaxing effects affords more relief to the parts in their state of tension. 
Abstraction of blood from the neighbourhood by means of leeches or 
scarifying, is, in many instances, an important part of local treatment 
during the inflammatory stage. Generally, the same indication is ful- 
filled by the antiphlogistic regimen, comprising a moderate unstimu- 
lating diet, saline purgatives, and diaphoretics. Purging is, however, 
to be avoided in any wound as much as possible. When the injured 
part is disturbed by the motion attending alvine evacuations, venesection 
may even be necessary ; but, as in all wounds which heal chiefly by 
granulation, depletive measures must be employed with caution. 

In a very few instances, where the wound is small and clean, with no 
lodgment of foreign matter, and a very quiet constitution, it has healed 
under the above treatment, by adhesion, throughout its whole extent. 
But it much more generally happens, even when inflammation has been 
limited to moderate bounds, that a tubular slough is detached from the 
point of entrance, and a little way beyond it, at which places the con- 
tusion has been greatest. 

When excessive vascular action ensues, the whole track of the wound 
may slough, and gangrene extend in any direction. 

The remaining indications of treatment are to be fulfilled in accord- 
ance with the general principles which regulate practice in lacerated, 
contused, and punctured wounds. The conditions which require primary, 
secondary, and second amputation, have already been considered. In 
the latter two cases, they are in no respect peculiar, or different from 
the circumstances which, in other injuries, are considered on sound 
principles to require similar treatment. 

POISONED WOUNDS. 

Poisoned wounds are those in which the introduction of noxious mat- 
ter accompanies solution of continuity. The poisonous principle is 
absorbed by the wound, enters the general circulation, and is rapidly 
distributed through the body, producing its pernicious effects on the 
various organs and the vital functions, but manifesting itself in a pecu- 
liar degree on the nervous system. On it certain poisons act so rapidly 
as to have given rise to the suspicion of their having some more direct 
mode of communication with the cerebro-spinal axis ; and this is sup- 
posed to be by the nerves of the part with which they have come in 
contact. The interval between the introduction of the virus, and the 
manifestation of its peculiar effects, differs in different poisons — varying 
also in each according to the quantity introduced, and the proximity of 
the point of entrance to the brain. Some of the more virulent varieties 
have exhibited their effects in so short a time as the sixth part of a 
minute ; but, generally, the interval is much longer ; and some, such 
as the virus of hydrophobia, may remain in the system for weeks, or even 



96 WOUNDS. 

months, before their characteristic results become apparent. During 
this period of incubation, as it has been termed, between the introduc- 
tion of the poison and the manifestation of its effects, it is supposed to 
become increased in quantity by exciting certain morbid changes in the 
blood, which, when once commenced, go on multiplying the poison. 
This process is named zymosis, from its supposed analogy to that of 
fermentation in saccharine liquids on the addition of the yeast-plant. 
Those poisons, which exhibit their effects very speedily, must, if they 
operate by a zymotic action, accomplish this process with extreme 
rapidity. 

There are, applicable to all poisoned wounds, certain general princi- 
ples of treatment, the local particulars of which are the most satisfac- 
tory in their results. The grand indication is, to prevent absorption of 
the virus, by immediate excision of the wounded part, by destroying it 
chemically with an escharotic, or by suction of the mouth, or by an 
exhausted cupping-glass — a ligature having been applied tightly round 
the part on the cardiac aspect of the lesion, and retained until either of 
the above operations has been performed, and until blood has flowed 
pretty freely from the wound. In some injuries, the gentlest of these 
means is amply sufficient to prevent bad consequences ; but, in others, 
one or all of them may be found to fail. Subsequent local complica- 
tions must be treated according to ordinary principles. 

These injuries, if at all severe, are generally followed by a stage of 
depression, which may be so great that the patient rapidly sinks ; and 
in nervous persons, very slight wounds, of a scarcely poisonous nature, 
arc followed by a shock, chiefly of a mental character, produced by the 
fright more than by the actual injury. During this stage the usual 
restoratives, of a mental and physical nature, are to be employed. 
These comprise gentle reassurance, and stimuli when necessary, of 
which ammonia and brandy are those usually preferred. If the patient 
live, reaction ensues, violent perhaps, but very generally asthenic. In 
the slighter forms, sedatives and mild antiphlogistics are to be employed 
with caution, in order to moderate the excitement of the system gene- 
rally, and of the local action which, during this stage, is often very 
severe. At the same time, gentle purgatives and diaphoretics should be 
exhibited, with the view of promoting elimination from the system. 
In many instances, however, there is already such prostration of the 
vital powers, that even in this stage none of the lowering measures can 
be employed. In some cases, the action is of a more specific character, 
and its treatment more uncertain ; while in others, the patient, after 
surviving both the previous periods, and after having been much 
depressed in vital energy by the poison, is brought into great danger 
by extensive sloughing and diffuse suppuration — conditions demanding, 
in addition to suitable local treatment, generous support and the judi- 
cious employment of all advisable means for maintaining the general 
strength. 

DISSECTION WOUNDS. 

Dissection w T ounds are frequently received without bad consequences, 
but sometimes they give rise to serious and fatal results. They are 



WOUNDS. 97 

chiefly dangerous when the health of the dissector is impaired from any 
cause, or when the virus is received from a body in which the cause of 
death has been puerperal disease, or acute inflammation of serous mem- 
branes. 

In slight cases, where bad results occur, the wound inflames in a few 
hours, and a pustule forms, which, on bursting, discharges a thin, un- 
healthy matter, and is converted into an acute ulcer. [The pustule is 
often umbilicoid, resembling a small-pox pustule. When opened in the 
early stage, serum escapes, which is nearly transparent, and the yellow 
appearance of the pustule still remains, showing that its colour does not 
depend always upon pus, but upon a fibrinous exudation. In a short 
time the vesicle becomes larger, and is refilled with serum, which, as 
the inflammation advances, will be found to contain pus. Should it 
heal by scabbing, the scab will be very thick, and composed in a great 
measure of cuticle, and will be very slow in dropping off. — Ed.] In 
more severe cases, erythema, erysipelas, whitlow, or inflammation of 
the lymphatics of the arm, may occur ; or chronic abscess with indura- 
tion, or acute abscess with purulent infiltration, may form in the axilla ; 
and this last complication frequently extends down the corresponding 
side of the thorax. In very severe cases, the axillary symptoms, com- 
mencing with acute pain and rapid formation of abscess, may occur 
before much irritation about the wound is perceived. The constitutional 
symptoms vary in intensity. In slight cases the constitutional affection 
may be sthenic and trivial, but in more severe instances, the asthenic, 
irritative, or even typhoid type prevails. In the worst instances, the 
systemic disorder appears before the occurrence of any very distinct 
local signs of inflammation. 

The treatment of the wound varies according to its form and the sub- 
ject from which the virus has been introduced 

If the body be that of a person who has died of acute peritoneal or 
puerperal disease, it is advisable, after washing, to make a perfect excision 
of the wounded part ; to allow oozing to go on for a short period, and if 
any time has been allowed to elapse between the infliction of the wound 
and the performance of excision, in addition to the above proceedings, 
to employ suction ; and after oozing has ceased, to touch the part very 
freely with the nitrate of silver, with the view of effecting destruction of 
any virus that may be lurking in it. In any ordinary case, it will be 
considered sufficient to wash the part instantly, to suck it well, and if it 
be a mere puncture, and do not bleed, to enlarge the opening slightly 
with a clean pointed knife, so as to encourage the flow of blood, and thus 
favour the removal of any matter. The nitrate of silver is frequently 
employed as an escharotic after suction, without excision, and is proba- 
bly useful by destroying or neutralizing the virus, if present, and by 
forming a crust of coagulated effusion, which prevents admission of 
noxious matter. I should never, in any case of poisoned wound, trust 
to an escharotic alone ; and it ought to be remembered that, if the nitrate 
of silver be used gently, it acts merely as an astringent, and that it is 
only when it is used very energetically, that it has an escharotic effect. 
It is advisable for some time to preserve the part at rest, in an elevated 
position, and to enclose it for a few hours in a soft soothing poultice. 

7 



98 WOUNDS. 

[In the treatment of pustules arising from dissecting wounds, I have 
found it very serviceable to apply the nitrate of silver freely to the 
inflamed surface contiguous to the pustule, and to enclose the limb 
in a large cold poultice of Indian meal. The burning sensation expe- 
rienced in dissecting wounds is increased by hot adhesive poultices, such 
as those made of ground flaxseed, but the Indian meal, being less glutinous, 
allows evaporation to take place whilst the skin is still kept moist. — Ed.] 
The digestive organs should be cleared out, the diet attended to, and all 
sources of local ,and constitutional irritation avoided. If constitutional 
or local symptoms supervene, they should be treated according to the 
principles already mentioned. 

MALIGNANT PUSTULE. 

Butchers and others who have to do with the bodies of the inferior 
animals, occasionally meet with wounds of a similar character, and 
requiring the same treatment as those to which the medical student in 
the anatomical rooms is liable. But there is one variety of wound thus 
obtained, which is somewhat peculiar in its consequences. The affection 
is characterized by the formation of a dark vesicle, rapidly followed by 
very painful inflammation and hardening of the dermis immediately 
below and around it. The vesicle bursts, the cellular tissue becomes 
involved, and sloughing phagedenic ulcer is produced. The constitu- 
tional disorder may at first be sthenic, but it very soon becomes typhoid, 
and as the local destruction extends, life is brought into the greatest 
danger. The constitutional and local treatment for malignant pustule 
is the same as that resorted to in the worst forms of sloughing phagedena, 
attended with great constitutional depression. 

WOUNDS INFLICTED BY THE BITE OF A DOO. 

Wounds inflicted by the bite of a dog are always regarded with appre- 
hension, because, although the animal seem healthy at the time, and 
may not become evidently rabid for several weeks after, yet a person, 
bitten during the stage of incubation in the animal, is liable to be 
attacked with the fatal disease, Hydrophobia. Many more persons, 
however, are bitten than are so attacked, even when the dog is manifestly 
affected. When the wound is inflicted through a portion of clothing, 
there seems to be less danger, probably owing to the teeth having been 
wiped clean in their passage through the dress. The virus contained in 
the saliva of the animal, whether dog, wolf, fox, cat, or badger, — for all 
these may become rabid, — must, as far as the integument is concerned, 
be applied to an abraded surface or wound, ere it can produce the disease. 
But several very striking cases, recorded by the late Mr. Youatt, seem 
to warrant the conclusion at which he arrived, namely, that mere con- 
tact with the mucous membranes may, without abrasion or breach of 
surface, communicate the disorder. 

The local treatment of a bite from a dog varies according as it is 
believed that the animal is healthy or not. If there seems every reason 
to conclude that the animal is perfectly well, not being even in the stage 
of incubation, and that the bite, consequently, was merely inflicted after 
provocation, or in self-defence, then the part should be well washed, a 






WOUNDS. 99 

cupping glass applied to withdraw any simply irritating matter, and the 
wound afterwards treated for granulation, like any other puncture or 
laceration. But if there be the slightest grounds for suspecting that the 
animal is rabid, or in the stage of incubation, instant and complete 
excision of the bitten parts is the only practice which can be trusted ; 
and, till this is accomplished, a ligature should be bound tightly around 
the limb between the point of lesion and the heart, so as to prevent 
venous return and absorption. An exhausted cupping glass is then to 
be applied, which will abstract any virus that may have penetrated 
more deeply, at the same time that it draws blood. The raw surface 
is finally to be treated with lunar caustic, which will arrest any persis- 
tent oozing, and, if possible, make security doubly sure, as regards the 
destruction of noxious matter. The nitrate of silver is sometimes 
employed alone, by persons of great experience, in preference to exci- 
sion. Amputation even is requisite, if the part, such as a finger or 
hand, is so much lacerated and bruised that complete excision cannot 
well be effected. Though a period of several days may have elapsed 
after the bite, still, until the commencement of the • local sensations 
which precede that of hydrophobic symptoms, the operation of excision 
or amputation should be performed. Subsequently, the tone of the 
general health is to be maintained, and mental anxiety as much as pos- 
sible calmed. Dr. Watson, in his admirable work on " The Principles 
and Practice of Physic," has so clearly stated what ought to be the 
proceedings of the surgeon regarding these wounds, that I cannot avoid 
transcribing his observations. " In the matter of cure, surgery, I fear, 
is as impotent as physic. Not so, however, in the matter of prevention : 
this is the most important part of the practice. The early and com- 
plete excision of the bitten part is the only measure in which we can 
put any confidence : and even here we are met with a source of fallacy. 
In the majority of cases, no hydrophobia w T ould ensue, though nothing 
at all were done to the w T ound. How can we know, then, that the 
disease is ever prevented by its excision ? No doubt many persons go 
through the pain of the operation needlessly. But in no given case can 
we be sure of this. They get at any rate relief from the most harass- 
ing suspense, with which they would probably have been tortured for 
months. And if a large number of bitten persons, who have suffered 
the wound to heal as it would, could be compared with an equal number 
who had had the bitten part cut out, hydrophobia would be found a fre- 
quent consequence of the bite in the first class, — a very rare conse- 
quence of it in the second. 

" Mr. Youatt, who trussed to caustic, and who had himself been bitten 
seven times, tells us that he had operated, with the caustic, on more 
than four hundred persons, all bitten by dogs, respecting the nature of 
whose disease there could be no question, and that he had not lost a 
case. One man died of fright, but not one of hydrophobia. Moreover, 
a surgeon of St. George's Hospital told him that ten times that num- 
ber had undergone the operation of excision there, after being bitten 
by dogs (all of which might not, however, have been rabid), and that it 
was not known that any one had been lost. Mr. Youatt, I say, trusted 
to caustic, and the caustic he used was the nitrate of silver. But I 



100 WOUNDS. 

advise you to trust to nothing but the knife, if the situation of the bite 
will allow you to employ it effectually. If the injury be so deep, or 
extensive, or so situated, that you cannot remove the whole surface of 
the wound, cut away what you can ; then wash the wound thoroughly, 
and for some hours together, by means of a stream of warm water, which 
may be poured from a tea-kettle, place an exhausted cupping-glass from 
time to time over the exposed wound ; and, finally, apply to every point 
of it a pencil of lunar caustic. If you cannot bring the solid caustic in 
contact with every part, you had better make use of some liquid escha- 
rotic — the nitric acid, for example. In my own case — and what I 
should choose for myself I should advise for another — if I had received 
a bite from a decidedly rabid animal upon my arm or leg, and the bite 
was of such a kind that the whole wound could not be excised, my rea- 
son would teach me to desire, and I hope I should have fortitude to 
endure, amputation of the limb, above the place of the injury. 

I say early excision is the only sure preventive ; but let me repeat 
that it will, in all suspicious cases be advisable (if, for any reason, the 
operation have been omitted in the first instance) to cut out the wound, 
or the cicatrix, within the first two months, or at any time before the 
symptoms of recrudescence have appeared. One would do it, though 
with less hope, as soon as possible after they had appeared ; but I do 
not expect to hear of excision being successful then in stopping the 
disease. Dr. Bright has recorded a case in which the arm was ampu- 
tated upon the supervention of tingling and other symptoms in the 
hand, in which the patient had been bitten some time before ; but the 
amputation did not save him." 

THE STINGS OF INSECTS. 

The stings of insects are rarely dangerous in this country, unless 
when very numerous, when inflicted on delicate parts, or on persons of 
an irritable constitution. If the sting be discovered by aid of a lens, it 
should be withdrawn by the point of a needle or fine forceps. Then, if 
it be a single puncture, mere suction for a considerable time will afford 
perfect relief; or the minute wound may be supplied with a drop of 
liquor potassse, which is supposed to neutralize or destroy the irritating 
matter. But this remedy must be applied to the exact spot alone, as, 
when undiluted, it exercises a powerful solvent effect upon the skin. 
Cold is then kept continuously applied by pure water or a saturnine 
lotion. When the stings are numerous, or the individual nervous, con- 
siderable depression may ensue, from the actual effects of the injury in 
the one case, or from mere fright in the other. Restoratives and stimuli 
may therefore be necessary ; and when reaction occurs, attended by 
nervous excitement and irritability, sedatives and mild antiphlogistics 
are indicated. When an insect gains entrance to the nostril, mouth, or 
fauces, its sting is particularly distressing, and, in the last-named case, 
even dangerous, owing to the great and rapid tumefaction of the mucous 
membrane, and consequent interference with respiration, demanding 
instant relief by local scarification, followed by fomentation, and counter- 
irritation externally. 



WOUNDS. 101 



EQUINA. 



Equina — a disease so named because animals of the equine genus, as, 
the horse, ass, and mule, are subject to it — is sometimes transmitted to 
man by inoculation, or contact, and sometimes also, it is said, by infec- 
tion. In the former case, the local consequences, up to a certain stage, 
are the same as in the more severe forms of dissection wounds. In both, 
there is fever of an asthenic type. The disease is afterwards character- 
ized by severe pains in the joints and limbs, followed by hard, circum- 
scribed swellings beneath the integument of these parts, which then 
ulcerates or sloughs ; by a sanious purulent discharge from the nostrils, 
but which, however, is not uniformly present ; by the formation of 
numerous characteristic pustules, which generally become gangrenous ; 
by a very low typhoid fever ; and by speedy death, which usually occurs 
about the end of the first fortnight. The pustular eruption is considered 
most characteristic of this disease, which is commonly called " Glan- 
ders," when this symptom is present along with the affection of the nasal 
passages, and "Farcy," when these peculiarities are absent. 

Hitherto the disease has been almost uniformly fatal, and the treat- 
ment adopted is merely palliative. The indications are, to support the 
system, and to alleviate local symptoms by fomentations, and deodorising 
lotions. Of the former, a solution of creasote ; and of the latter the 
chlorides dissolved in water are the most efficient. 

THE BITES OF SERPENTS. 

The bites of serpents lead to results varying according to the species 
which inflicts them. The common viper is the most dangerous that is 
found in this country, but its bite is very seldom fatal. The effects are 
often distressing, but are scarcely dangerous, except in children, and in 
delicate persons of great susceptibility. The local irritation is repressed 
by the continuous application of cold, or subsequently soothed by heat 
and moisture, if it proceed to actual inflammation. In this case mode- 
rate antiphlogistics may be required. Any other consequences, similar 
to those which result from dissection wounds, are treated on similar 
principles. 

" Of the numerous American serpents two species only are known 
to be venomous — the rattlesnake and copperhead. Eight varieties of 
the former have been familiar to naturalists, and two others have been 
discovered lately by Humboldt 1 and Bonpland. All are poisonous, but 
in particular the crotalus durissus, horridus, and miliarus. The copper- 
head (boa crotaloides) sometimes called the bastard rattlesnake, is also 
exceedingly malignant. All these reptiles are furnished with long 
teeth, or poisonous fangs, the roots of which are surrounded by a bag 
or reservoir containing an active or virulent poison. This poison is 
discharged into the wound through a small fissure of the tooth situated 
near its extremity, and in many instances very quickly proves fatal both 
to man and to inferior animals. As regards the effect of the poison, 

1 These are the Crotalus Cumanensis and the Crotalus Laflingii. See Recueil d'Obser- 
vations de Zoologie et Anatomie Comparee, 4to. 



102 WOUNDS. 

much will depend upon the size of the animal bitten — death being 
produced more readily in the smaller than in the larger animals. 
According to the experiments of Vosmaer, sparrows, finches and other 
small birds died in about four minutes, while a mouse died in a minute 
and a half. The deleterious operation of the poison will also depend 
materially upon its quantity, and upon the season of the year at which 
the wound is inflicted. To ascertain the effect of the bite of the rattle- 
snake, several experiments were made by Captain Hall, of Caro- 
lina, upon dogs, cats, chickens, and frogs. Three dogs were bitten in 
succession by a snake four feet long. The first died in less than a 
quarter of a minute, the second in two hours, and the third in three 
hours. Four days after two other dogs were bitten ; one of which died 
in half a minute, the other in four minutes. Several experiments, 
nearly similar, were made by the late Professor Barton on chickens. 
Of three chickens bitten on three days successively, one died in a few 
hours, another lived much longer, and the third recovered, after having 
been exceedingly swelled. On the fourth day, several other chickens 
were bitten, but recovered without a bad symptom. 

" The rattlesnake is more lively, and its venom more active, during 
very warm weather than at any other period : upon the approach of 
cold seasons it becomes languid, and then strikes reluctantly, and 
frequently without any ill consequence. The effects produced by the 
poison either on the human body or on the lower animals, vary according 
to the parts wounded, the depth to which the fang penetrates, and the 
quantity and strength of the venom in the reservoir. In many instances 
death follows in a few seconds or minutes, and in others not until many 
days or weeks. The interesting case detailed by Sir Everard Home, 
which I witnessed whilst a student in London, furnishes striking proof 
of the speedy operation of the poison of the rattlesnake, and at the 
same time affords incontestable evidence that it may remain a long time 
in the system before death is produced. The patient was teasing a 
large rattlesnake with the end of a foot rule, but could not induce the 
animal to strike; the rule accidentally dropped from his hand, he 
opened the door of the cage to take it out ; the snake immediately darted 
at the hand, and inflicted four wounds — two on the back part of the 
first phalanx of the thumb, and two on the side of the second joint of 
the forefinger. The hand soon after began to swell, and in the course 
of ten or eleven hours the whole arm, axilla and shoulder were very 
much tumefied, and cold. There was an unusual coldness also through- 
out the skin of the whole body. At this period, the mind of the patient 
was perfectly collected ; but immediately after the accident he talked 
incoherently, owing probably to strong drink, which it was ascertained 
he had taken before he > was bitten. From the axilla the swelling 
extended down the side, and blood was extravasated under the skin as 
far as the loins, giving the back a mottled appearance. The skin over 
the whole body became warm, faintings occurred repeatedly, vesications 
appeared in different parts of the body, a large abscess formed on the 
outside of the elbow, and discharged half a pint of reddish matter; 
mortification took place in the axilla, in the forefinger, and some other 
parts, and finally destroyed the patient, after he had laboured for 



WOUNDS. 103 

eighteen days under the most distressing symptoms. Upon dissection, 
the body presented a natural appearance (with the exception of the arm 
that had been bitten), and the wounds made by the fangs of the reptile 
had healed. 

"Instances have occurred, both among the Indians and among the 
white people, who inhabit the mountainous and thinly-settled parts of 
our country, of almost instantaneous death from the bite of the rattle- 
snake. On the other hand, it is very certain that many persons wounded 
by this animal have sustained very trivial injury, if any. In such cases, 
it is probable that the teeth enter obliquely, and do not penetrate the 
true skin, or that the reservoirs at the roots of the fangs have been 
empty, or the virus itself, owing to particular circumstances, so modified 
or changed in its properties or in such small quantity as not to produce 
fatal effects. Again, — where death has followed almost immediately or 
shortly after the wound, the poisonous fangs have probably penetrated 
directly an absorbent artery or vein, and conveyed the noxious matter 
at once into the circulation. According to Catesby, the Indians very 
soon ascertain when this has happened, and under an impression that 
the wound is necessarily fatal, apply no remedy. Upon these principles 
it will be easy to account for the supposed good effects of the numerous 
and diversified remedies at different times proposed for the cure of the 
rattlesnake ; inasmuch as there is reason to believe that nature, unas- 
sisted, is often sufficient to accomplish a cure, or that a sufficient quantity 
of virus has not been inserted to produce death. 

" The poison of the rattlesnake is of a yellow colour tinged with 
green : during extreme heat, and particularly in the procreating season, 
it becomes of a much darker hue. The copperhead is equally poisonous 
with the rattlesnake ; but few experiments have been made to ascertain 
its peculiar character." 1 

[" But the best plan of all, is that recommended by Sir David Barry. 
He directs, first, that an exhausted cupping-glass shall be applied over 
the wound, for a few minutes ; next, the glass is to be taken off, and the 
wound freely excised ; and lastly, the glass is to be applied again, in 
order to promote the flow of blood, and cause the re-exuclation of any 
of the poison, that may have found its way into the neighbouring blood- 
vessels. The cupping-glass, used in the manner we have just detailed, 
possesses all the efficacy and none of the disadvantages of ligatures ; 
for, without interrupting the general circulation of the limb, it produces 
a complete afflux of all the fluids in the vicinity towards the wounded 
part, and entirely prevents them from conveying their contaminated 
contents towards the centre of the circulation. If the glass is applied 
in this manner, it is far from being advantageous (as is generally sup- 
posed), to make incisions or scarifications near the wound, whether before 
or after its excision ; for the object is to concentrate the course of the 
blood towards the original wound itself, so that it may carry the venom 
with it, as it escapes ; and this object would be counteracted by any 
extraneous incisions. 

" The treatment of snake-bites during the first stage, consists first, in 

1 Gibson's Surgery, vol. i., pp. 79-81. 



104 WOUNDS. 

the administration of powerful diffusive stimulants, such as hot brandy and 
water, ammonia, or the eau de luce, to support the nervous system ; and 
secondly, in the use of remedies which may be supposed to eliminate 
the poison from the blood. Thus, if there is no vomiting, it should be 
excited by a mustard emetic, to get rid of the vast quantity of bile that 
is often formed in the blood, and secreted by the liver under these cir- 
cumstances ; if, however, vomiting is spontaneous, and too violent, it 
should be checked by a large dose of solid opium, and a mustard poultice 
to the epigastrium. But the principal remedy seems to be arsenic, 
which has long been popular for these accidents, in the East Indies. It 
is usually administered there in the form of a nostrum, called the Tan- 
gore pills, each of which contains a grain of it, combined with certain 
unknown acrid plants. The efficacy of this mineral was also fully 
established in the West Indies, by Mr. Ireland, surgeon to the 16th regi- 
ment, who employed it with perfect success, in five cases of the bite of a 
serpent, which had previously killed several officers and men, some within 
six hours, and all within twelve. He combined f 3ij of the liquor arseni- 
calis with gtt. x. of tinct. opii (to prevent vomiting), f ^iss of peppermint 
water, and f 3ss of lime juice. This draught, which contains a grain of 
the arsenious acid, was given every half hour, for six or eight doses, till 
it produced copious purging (which was encouraged by clysters), or till 
the symptoms were ameliorated. The swelled parts were well rubbed 
with a liniment of olive oil, turpentine, and liquor ammonia ; — and the 
patients, although for a time greatly debilitated, were soon able to return 
to their duty." 

"If the local symptoms are very slight, stimulating embrocations, and 
hot fomentations, with leeches, may be sufficient! But if the swelling- 
is rapid and extensive, or the constitution is much affected by the poison, 
free and extensive incisions into the swelled parts are indispensable. 

" The constitutional treatment of the second stage must be regulated by 
the symptoms actually present ; it will most likely require a combination 
of cordials, opiates, and tonics."] 1 

1 Druitt's Surgery. 



105 



CHAPTER IV. 
BURNS. 

A burn is an injury inflicted on the body by a degree of heat higher 
than is compatible with healthy action in the part affected. Burns are 
produced either by actual contact with flame or heated bodies, or by 
radiation of caloric from them ; and their severity depends on the 
proximity and intensity of heat, the length of time it has been applied, 
and the nature of the heating agent, as also that of the injured part. 
Thus, flame, which can exist only at a very high temperature, and which 
speedily induces combustion of the tissues ; steam, whose latent heat 
becomes sensible on condensing ; metals whose density and conducting 
power are great ; and oil, which maintains a high boiling point, and 
adheres to the skin ; — all produce severe burns, which, eceteris paribus, 
are most severe on those parts where the epidermis is thin and delicate. 
This condition, when produced by heated liquids or vapours, is usually 
styled a scald, the term burn being then restricted to those cases where 
a dry body has been the agent of injury. As the heat of solid bodies 
is frequently much greater than that attained by fluid substances, except 
metals in a state of fusion, the former may produce very deep burns ; 
while liquids, by flowing over a large surface, cause more extensive, 
though comparatively superficial lesions. 

The Classification now generally employed, as being the most scien- 
tific and convenient, is that of Dupuytren, who arranged all burns into 
six classes or degrees ; the tissues involved, and the amount of lesion 
being made the basis of classification. The first degree consists of a 
superficial inflammation of the integuments, unattended by vesication. 
The second, in addition to the rubefaction, is accompanied by vesicles. 
The third exhibits the skin partially disorganized, the cuticle, together 
with the papillary surface of the cutis, being destroyed and converted 
into a thin eschar. In the fourth degree, the whole thickness of the 
skin, including, sometimes, the subcutaneous cellular tissue, is carbo- 
nised. The fifth degree only differs from the preceding in penetrating 
more deeply ; an eschar being formed which comprehends the several 
soft tissues beneath the integument, down to a variable depth, perhaps 
even to the bone itself. In the last or sixth degree, the whole thick- 
ness of the limb or part is carbonised. 

Consequences of Burns. — If at all severe or extensive, this kind of 
injury is liable to be followed by many serious consequences, which, 
though generally more or less combined in practice, may, for better 
description, be divided into two orders — namely, Local and General ; or, 
into Inconveniences and Dangers ; the former being hostile to the pre- 



106 BURNS. 

servation of the comfort or limbs of the patient — the latter being dan- 
gerous to life itself. By a due knowledge and consideration of these, 
the treatment and prognosis must in every case* be regulated. The 
first order, which consists of those local effects not directly dangerous 
to life, consists, with a single exception, of various conditions attend- 
ing cicatrization, and productive of functional lesions, partial or. com- 
plete. They have been enumerated under the heads of adhesions, 
deformities, and mutilations ; to which may be added disfigurements, 
and affections of the cicatrix. The disfigurements consist of those 
unseemly cicatrices, especially on the face, neck, and other exposed 
parts, which merely affect the appearance rather than entail any serious 
discomfort. They are produced principally by burns of the third degree, 
by slight cases of the fourth, and sometimes also by severe instances of 
the second, when the epidermis forming the vesicles has been torn off, 
exposing the cutis to the stimulus of the atmosphere, to irritation and 
subsequent suppuration. The adhesions imply those conditions in 
which, during cicatrization, contiguous tissues or surfaces, which in their 
natural state move freely on each other, have become mutually adhe- 
rent, thereby abridging voluntary motion, as when a cicatrix adheres 
firmly to a muscle, tendon, or aponeurosis beneath ; or these latter to 
one another. Deformities are constituted by any considerable altera- 
tion in the shape of an organ, or in the relation which one part naturally 
bears to another. They may be produced in two ways ; either by con- 
traction of the cicatrix, or by destruction of muscular antagonism. 
The cicatrix following a burn is said to have a greater tendency to con- 
tract, than after any other species of injury. Like all new, and lowly- 
organized structures, it is very liable to absorption, which makes the 
contraction and puckering of the tissues around go on long after the 
sore has healed. Wherever a portion of skin has been destroyed in 
this manner, as in a burn of the fourth degree, its place is eventually 
supplied, not altogether by a new and permanent structure, but to a 
very considerable extent by the uninjured integument in the neighbour- 
hood, which, by the steady drag exercised on it by the gradual contrac- 
tion of the cicatrizing ulcer, or the cicatrix, is drawn together towards 
a central part, which is at last occupied by the cicatrix, now much dimi- 
nished in size, shrivelled, and sometimes almost of a horny texture. 
The surrounding integument stretches to a certain extent, more espe- 
cially in those parts where it is loosely connected with the tissues below : 
but if the loss has been very extensive, the requisition on the integu- 
ment around will be proportionately large, and this demand may prove 
more than its extensile qualities can supply. Accordingly, if a burn be 
so situated, that flexion or other posture of a neighbouring articulation 
will relax the skin around the seat of injury, the steady drag on the 
integuments, added to the natural tendency of the limbs to preserve a 
slightly flexed position, will produce, if not guarded against, a perma- 
nent flexure of the joint. The same remarks apply with still more 
force, when the deeper-seated parts have, as well as the skin, been 
destroyed. Thus the fore-arm has been immovably bent on the arm, 
the latter bound to the side, the lower jaw dragged down to the sternum, 
and the head drawn back between the shoulders. When the injury is 



BURNS. 107 

situated on the extensor aspect of an extremity, the tendency, above 
mentioned, of the limbs to sustain a slightly bent position, is in general 
sufficient to counteract the extending force of the contracting cicatrix. 
This is not, however, always the case, for the fingers have frequently 
been bent backwards upon the metacarpus, and the foot has been so 
twisted and deformed that all trace of its original conformation has 
been destroyed. Deformities from this cause, and to this extent, are 
now, however, much less frequently met with than formerly ; though, 
in injuries of such a nature, the motions of the joint almost always 
remain more stiff and constrained than natural, and are farther restricted 
by the abnormal adhesions formed between the cicatrix and the subja- 
cent parts. Again, in those cases where the tissues beneath the integu- 
ment are destroyed, as in a burn of the fifth degree, in which the con- 
tinuity of muscles, tendons, or aponeuroses has been interrupted, the 
contractions of the cicatrix, together with the unnatural adhesions, fre- 
quently cause deformity, fixation, and even dislocation of a neighbour- 
ing joint. As in other injuries, when the solution of continuity affects 
a nerve, loss of voluntary motion or of sensation must ensue in the parts 
supplied by it on the peripheral side of the injury, by which occurrence 
the antagonism of two sets of muscles may be destroyed, and deformity 
produced. Mutilations consist in the partial or complete loss of an 
organ. They are immediate in all burns of the sixth degree, and in 
those of the fifth, in which the possibility of saving a useful limb is at 
once rendered hopeless. They are consecutive, when caused subse- 
quently either by the violence of inflammatory reaction inducing exten- 
sive gangrene, or where the limb, as it remains, is so utterly useless as 
to necessitate amputation ; an operation which is also sometimes neces- 
sary to save life when it is endangered by hectic from the exhausting 
effects of profuse and prolonged suppuration. The affections of the 
cicatrix are chiefly excessive contraction, fissure, ulceration, and irrita- 
bility. As it is less highly organized than the original integument, it 
is peculiarly liable to the first three of these conditions, in conformity 
to the general law, that newly-formed and lowly-organized structures 
are much more prone to absorption, to inflammation, and other diseases, 
than older and more highly constituted tissues. Irritability of the 
cicatrix may be the result of a nervous filament or trunk being impli- 
cated in it, as occasionally happens after an ordinary amputation ; or 
it may occur without any such apparent cause. • 

The second order of consequences, comprising the general or constitu- 
tional effects, are those which more immediately endanger life. They 
may be arranged, chiefly according to the periods at which they occur, 
into six groups. First, — when a large extent of surface is burnt though 
but superficially, and more particularly when to the third degree, a 
shock is communicated to the nervous system, either by intense pain 
excited in the wide expanse of integumentary nervous web which is 
injured, or by the sudden destruction of the functions of the integument. 
It is believed that tliis shock occasionally causes instantaneous death by 
asthenia, or the asthenic form of syncope — the heart ceasing to act from 
its irritability or contractile power being annihilated. The same result 
may take place when the burn, though of less extent, has penetrated 



108 BURNS. 

more deeply and injured some vital or important organ ; but, with this 
exception, it is a well-ascertained fact that burns are more dangerous 
from their extent than from their depth. Second, — more frequently it 
happens that death is not immediate. There is great depression and 
collapse of the vital powers, which gradually sink in a few hours. The 
immediate cause of the fatal issue in this instance may be, as in the for- 
mer, asthenic syncope, with this difference, that here the functions of 
the heart are slowly and gradually suspended, instead of being instantly 
arrested. Females, children, and persons of a nervous and irritable 
temperament, are most liable to sink in this manner. In other cases, 
death is preceded by typhoid symptoms, low muttering delirium, and 
coma. When the functions of a large portion of integument are suddenly 
suspended, the healthy balance between them and those of the lungs is 
destroyed ; the latter become, with the other internal organs, greatly 
congested, and soon cease to effect proper aeration of the blood. This 
leads to more retarded circulation in the pulmonary system ; the brain 
is supplied with imperfectly purified blood ; coma ensues, which still 
further retards the flow of blood through the lungs ; and death results 
at last, from apncea, accelerated by coma. Third, — In other cases, the 
collapse goes off, and is succeeded by an imperfect and feeble reaction, 
attended with great irritability and excitement of the nervous system, 
under which the patient may sink exhausted. Constitutional debility 
and irritability predispose to this termination. Occasionally, death has 
occurred about this period from tetanus, or from convulsions. Fourth, 
— On the disappearance of collapse, vigorous reaction may ensue. When 
this is confined within proper limits, it is the first step towards recovery ; 
but when excessive, and accompanied by very high symptomatic or in- 
flammatory fever, it is equally perilous to life, as would be its deficiency. 
Sometimes, accordingly, the patient dies during the stage of excessive 
reaction. At this period, also, congestion and inflammation are very 
apt to occur in the mucous membranes, and several internal organs, 
more especially the lungs, the intestines, and the brain. These serious 
complications render the prognosis much more unfavourable, and fre- 
quently prove the chief causes of death. The upper portion of the duo- 
denum is the part of the intestinal canal which is most frequently 
affected. Sometimes the inflammation here leads to ulceration, especially 
in young persons ; and, occasionally, during the ulceration, a small 
artery is opened, hemorrhage ensues, and the patient generally dies, 
either from a single profuse loss of blood, or from a more sparing dis- 
charge, frequently repeated. Death in this instance takes place by that 
form of syncope in which the heart primarily ceases to act, from the 
want of a sufficient volume of blood to excite its contractions ; the ner- 
vous system being consecutively affected by the deficiency of the nutri- 
ent fluid. This mode of death is accordingly called, by Dr. Watson, 
anaemia. Of hemorrhage from the above cause, about a dozen cases are 
on record. Gangrene, from excessive inflammatory reaction, may prove 
fatal by a combination of asthenic syncope and coma. Any of the 
serous membranes, or the organs which they invest, may, in like man- 
ner, be attacked by inflammation. As a general rule, those internal 
parts are most apt to suffer, which are nearest to the external lesion. 



BURNS. 109 

Apoplexy occasionally occurs from the fifth to the seventh day. Du- 
puytren considered this to be owing to idiosyncrasy, but it is more sim- 
ply explained by referring it to vascular excitement in a person, the 
arteries of whose brain are already in a state of disease. Confirmed 
drunkards have been attacked, about this period, with delirium tremens ; 
and in pregnant females, the premature expulsion of the foetus is said 
to have occurred. Fifth, — During, and after the detachment of sloughs, 
new dangers arise. In bad constitutions, or where the powers of life 
are much enfeebled, the separation of the eschar by ulcerative absorption 
may not have been preceded by a sufficient effusion of plastic lymph on 
the layer of living tissue next to the dead mass ; accordingly, if any 
considerable artery, or even vein, has been involved in the slough, 
dangerous or fatal hemorrhage may take place from its open mouth, 
which has not been sealed up, as, under a more favourable state of the 
system, it would have been. The same result may ensue from an artery 
being denuded at this period, and afterwards ulcerating. The possibility 
of such an occurrence suggests the propriety of using no force in re- 
moving the sloughs, lest the blood-vessels be not yet prepared for the 
separation. When the eschar has been very extensive, persons have 
occasionally died soon after its separation without any very obvious 
cause, unless it has been owing to the sudden exposure of a large ulcera- 
ting surface to the irritation of the atmosphere, inflicting a second shock 
on the system, which, though it was able to withstand the primary effect 
of the injury, succumbs to this second attack in its now enfeebled state. 
If this be the true explanation, then the raw surface, when of large 
extent, should be exposed only partially, as seldom as possible, and for 
as short a time as practicable, at each dressing. During suppuration, 
phlebitis and pysemia have sometimes occurred, and destroyed life with 
the most urgent typhoid symptoms. After all the preceding dangers 
are past, if the process of cicatrization, over a large surface, be tedious, 
and suppuration very profuse, the exhausting effects of this drain on the 
system, combined with long confinement, tend to induce hectic fever, 
under which the patient may sink. The fatal issue is sometimes much 
accelerated by the development and rapid progress of phthisis pulmo- 
nalis. A more common adjunct of the hectic, is colliquative diarrhoea, 
from irritation and ulceration of the intestinal mucous membrane, par- 
ticularly in the vicinity of Peyer's glands on the lower part of the ileum. 
Sixth, — Even the period of cicatrization, according to Dupuytren, is not 
exempt from danger ; for he mentions that when this process has been 
nearly or entirely completed, persons have sometimes died suddenly and 
in a manner unaccounted for, even on dissection. This singular occur- 
rence may be supposed to be connected with the suppression of the 
purulent discharge, which, though not natural, yet from its long con- 
tinuance before cicatrization was effected, had become a habit — and, in 
fact, necessary, in some degree, to the constitution. 

Post-mortem Appearances. — The local effects of burns have already 
been sufficiently described to enable any one to understand what condi- 
tions may be expected on examination of the parts with the scalpel, 
when opportunity offers for so doing. In persons who have died imme- 
diately, or shortly after extensive burns, from the primary shock, 



110 BURNS. 

Dupuytren says, the intestinal mucous membrane presents, in many 
places, bright red patches of variable size, and other marks of great 
congestion, — the fluids of this canal, especially in the stomach, being 
deeply tinged with blood. Other observers, however, have not found 
the preponderance of congestion in the mucous membranes to be so 
great, or so constant, as Dupuytren in such cases has represented it. 
The cerebral sinuses are gorged with blood ; the brain and its mem- 
branes very much injected, its ventricles filled with a pinkish serum ; 
and a similar fluid is found within the peritoneum, pleura, and pericar- 
dium, — these being in some parts dotted, or streaked with red points 
and lines of vascular injection. When the patient dies during reaction, 
many of the above-mentioned appearances will be present. The symp- 
toms during life will assist in pointing out which organ, if any, will be 
found the principal seat of inflammation or of congestion. 

The prognosis of burns, except of those which are very trifling, is 
always uncertain in the early stages ; not only from the possibility of 
any of the preceding fatal terminations occurring ; but also from the 
circumstance that it is frequently impossible, till an advanced period, 
to predicate the amount of lesion. In some instances it is doubtful at 
first how far the destruction has extended ; and in others the immediate 
injury is followed by a secondary sloughing of the tissues, consequent 
on the violent inflammatory reaction in these parts, the vital powers of 
which were considerably lowered, though not entirely destroyed at the 
moment when the injury was inflicted? In forming a prognosis, we 
must be influenced by a consideration of these points, and of the sex, 
age, constitution, previous habits, and present sanatory condition of the 
patient ; as also of the extent of the burn in superficial area, and in 
depth ; — of its relative situation, and the nature of the part. Females, 
children, and persons of a weak, nervous, and irritable temperament, 
are, as might be expected, more liable to the dangers attendant on this 
kind of injury than males, adults, and those of a stronger, and less ex- 
citable constitution. Old age again, which by its accompanying debility 
is exposed to the dangers of the former class, and is little able to survive 
the shock, or to support the tedious suppuration, is, however, less liable 
to those congestive and inflammatory attacks which so often complicate 
the injury in younger and more full-blooded individuals. Previous per- 
nicious habits, present disease, or any circumstance which tends to 
weaken the general health, increase the danger. Intemperance in alco- 
holic liquors, is a strong predisponent to a fatal issue in this, as in other 
serious injuries. These various conditions do not all agree in producing 
danger in the same manner. Thus a weak and nervous individual, be 
the weakness from whatever cause, whether from the extremes of age, 
from disease, or from previous irregularities, is peculiarly liable to sink 
under the primary shock. To a strong plethoric adult the period of 
reaction, with its internal congestions, and it may be inflammations, is 
the most dangerous. Asthenic persons again, if they have survived the 
preceding stages, are, especially when of the strumous diathesis, prone 
to succumb during the period of suppuration and hectic. It was before 
stated that the danger of a burn is more proportioned to its extent of 
surface than to its depth, except when in the latter case vital or im- 



BURNS. Ill 

portant organs have suffered. The depth, on the other hand, more than 
the superficial area, regulates the amount and nature of the local se- 
quelae. The influence of relative situation is shown by a burn, which 
in one place would be comparatively unimportant, producing, in another 
site, very serious consequences. 

With regard to the local results, it may be considered a general rule, 
that, other things being equal, a burn will produce an amount of defor- 
mity directly proportional to the freedom of action naturally enjoyed 
by the part which is the seat of injury. Thus, when in the neighbour- 
hood of a joint, its fixation ; — when near the mouth, hideous distortion ; 
close to the eyelids, their eversion, ectropium, adhesion of their margins 
to one another — are conditions easily induced. The influence of rela- 
tive situation in causing danger, is exhibited by otherwise insignificant 
burns of the scalp, exciting inflammation in the brain or its membranes ; 
of the thorax and abdomen, in inducing the same morbid action in the 
serous linings of these cavities, and in the latter situation, when deep, 
predisposing to hernia or protrusion of some of the viscera, from weak- 
ening of the abdominal parietes. 

Again, when situated near the orifices of mucous canals, the transit 
through them may be materially interfered with, whilst their natural 
secretions, coining in contact with the sore, may deteriorate its action, 
and retard its healing. Thus in a scald of the mouth, fauces, and pha- 
rynx, from an attempt to swallow a boiling fluid, dysphagia or difficulty 
of deglutition will ensue, which, if the injury be severe, may not pass 
off with the inflammation, but may continue permanently, through con- 
traction or stricture of the upper part of the oesophagus. But there is 
here a more immediate source of danger : the scalding liquid may pene- 
trate into the larynx as far as the glottis, and excite acute inflammation 
of it and the epiglottis ; or the same result may take place by propaga- 
tion of the action from the pharynx, without the fluid passing below the 
epiglottis into the larynx at all. This condition will produce dyspnoea, 
or even death by apnoea if not relieved. In these instances it is believed 
that the liquid does not pass into the oesophagus, or farther down the 
larynx than the rima glottidis ; the spasmodic muscular action, in both 
these parts, effecting closure of their respective canals. Occlusion of 
the puncta lachrymalia may ensue from a burn in their neighbourhood. 
Dysuria results when the genitals are implicated ; and, in the female, 
the contact of the acrid urine may aggravate the injury. When close 
to the anus the pain experienced during defecation induces the patient 
to perform this as seldom as possible, and constipation is the natural 
sequence. The situations, then, on which burns are most dangerous, 
are the head and neck ; the geuitals, particularly in children ; and the 
trunk generally. When on the hands and feet, tetanus has followed 
this, as well as other injuries of the same parts. 

It has been stated that a fatal result will almost certainly take place 
from a burn of the first or second degree, which involves half of the 
entire surface of the body ; from one of the third grade, affecting a 
quarter ; and from those of the fourth, fifth, and sixth degrees, in which 
the eschar comprehends more than a square foot. No doubt, these 
points will frequently be found to be correct ; but from what has been 



112 BURNS. 

said above, it will be evident that under particular, though by no means 
unusual, circumstances, a very much smaller amount of injury may lead 
to death. 

The First Degree is most commonly caused by contact with heated 
liquids or vapours, or by radiation. The four common symptoms of 
inflammation are present, — namely, redness, heat, pain, and swelling ; 
while the absence of vesication distinguishes this from the next degree. 
The redness is of a bright rosy hue, diffused — not circumscribed, disap- 
pearing momentarily under pressure, and very similar to that of ery- 
thema, of which- this may be considered a traumatic form. The pain is 
acute, of a smarting, or burning character, and it generally lasts as 
long as the rubefaction remains. The swelling is but slight, except 
when on mucous membranes. These symptoms disappear by resolution 
in a few hours, or at most, in two or three days. In more severe cases, 
a slight desquamation of the cuticle ensues in the form of light furfura- 
ceous scales. A degree of tenderness in the part frequently remains 
for a few days longer. 

When the shock has been very great, collapse is present ; marked by 
a weak, fluttering, and irregular action of the heart, and a pulse almost 
imperceptible at the wrist. The person is scarcely conscious, his sensa- 
tions are impaired, and his gaze is vacant. When reaction is established, 
symptoms of any of the complications already enumerated, may exhibit 
themselves. 

Local Treatment of First Degree. — In burns of the first degree, the 
objects of local treatment are to mitigate pain and prevent effusion. 
When an extensive surface is affected, the whole should not simultane- 
ously be exposed to the atmosphere ; and any necessary exposure should 
be as brief as possible. In slight burns, local treatment may alone be 
requisite, consisting in the steady application of cold for several hours, 
either by simple immersion or wet cloths. Immersion is of course only 
applicable when the surface involved is small and suitably situated, and 
when no collapse is present. The water employed must be kept cold 
by frequent renewal. When the part is not conveniently situated for 
immersion, it should be closely, but at the same time lightly, enveloped 
with a single layer of soft linen or cotton kept constantly wet with 
some cold liquid. Simple water may be employed, with the addition, if 
thought necessary, of a little alcohol, to increase the evaporation and 
the consequent cold. Dupuytren used an acetate of lead lotion, which 
he considered sedative and astringent : — it is a very excellent applica- 
tion. After the incipient inflammation has been thus checked in the 
onset, the part, if of any extent, must be defended, alike from the stimu- 
lus of the atmosphere, and the depressing influence of cold ; one or both 
of which might injure it in its present delicate condition. This may be 
variously accomplished, either by rolling fine carded cotton or wadding 
around the part ; or by varnishing the surface with a thin layer of some 
bland adhesive substance, which will, for a time, perform the part of an 
insensible cuticle. For this purpose, mucilage of gum arabic, or traga- 
canth, or the ethereal solution of gun-cotton known by the name of 
collodion, — may be employed. The collodion, and probably the muci- 
lage also, seem to act in two ways ; — first, by protecting the surface 



BURNS. 113 

from contact with the atmosphere ; and — second, by contracting to a 
certain extent as it dries, which, together with its close adhesion to the 
cuticle, tends to keep up a degree of pressure or compression, that proves 
beneficial to the weakened part, as well by affording it support, as by 
favouring the absorption of any slight interstitial effusion. The varnish 
may be removed, when the vascular action in the subjacent integument 
has quite subsided to its natural standard. If applied, however, over a 
large surface, it might prove injurious by mechanically obstructing the 
cutaneous transpiration of the part ; and this would favour the occur- 
rence of vesication. Such an objection does not apply to cotton. For 
a like reason, the aqueous mucilages are less objectionable on the large 
scale, than collodion, which is quite impervious to moisture ; while the 
former readily imbibe a little from the surface below, which not only 
relieves the subjacent integument, but also prevents undue desiccation 
of the protective layer, and its consequent cracking and peeling off. 

But, where a very large surface is burnt, and when the depression is 
considerable, the continuous application of cold cannot be had recourse 
to, as it would tend still farther to lower the system. In this case, a 
warm opiate fomentation may be employed, which will 'greatly mitigate 
the pain ; and, subsequently, the cotton or varnish may be employed as 
before. Some persons employ the cotton in the first instance ; and this 
will be the most judicious treatment in many burns of the first and 
second degrees, where, from the great extent of injured surface, neither 
cold nor warm lotions can be conveniently employed. The cotton, more- 
over, has this obvious advantage, that when once applied in such cases, 
it need not soon to be disturbed ; while liquid appliances, on the contrary, 
require frequent or constant supervision and renewal. This peculiarity 
is a decided recommendation for its employment in those distressing 
cases of great severity, in which all hope of life is at once destroyed ; 
and in which, therefore, the treatment ought from the first, to be chiefly 
directed to soothe the suffering of the last moments. A popular appli- 
cation, which deserves mention as a ready substitute for the cotton or 
varnish, after the vascular action has been repressed, — is flour, dusted 
thickly over the reddened surface. It is applicable to burns of the first 
degree ; but not when the injury has caused, or is likely to induce vesi- 
cles ; for, on the bursting of these, the effused fluid cakes the flour into 
a mass, which hardening, irritates, instead of protecting the skin. 

Stimulant applications have been recommended from the commence- 
ment ; but, in the early stages of all burns, they tend to increase the 
vascular action, and so carry the injury to a higher degree than it 
would otherwise have attained. Turpentine has been considered to 
exercise a constringing action on the vessels of the integument, and 
thus to prevent effusion ; but this substance on many skins, even when 
in the healthy condition, is itself a very powerful rubefacient. In slight 
burns of the face, from explosions, by which the eye is injured by par- 
ticles of gunpowder stuck on, or into the conjunctiva, all the large 
grains should be removed at once ; after which, linen cloth, kept very 
wet with cold water, or a cold, light, very moist, bread-and-water poul- 
tice enclosed in a cloth, forms the best application, and is to be laid 
across the eyes, the patient lying in bed. The water here dissolves 



114 BURNS. 

and carries off the nitre of the powder; while its remaining constituents, 
sulphur and charcoal, are washed away. Those particles which remain 
after a day or two, should be carefully picked out by any fine-pointed 
instrument. The operation, which has been advised, of picking out 
with the point of a needle, all particles of gunpowder that have lodged 
in the skin, would be, in many instances, where the whole face and 
head are thus tattooed, as impossible to execute as it would be danger- 
ous ano\. cruel to attempt. 

The treatment of pharyngitis, or laryngitis, following an attempt to 
swallow boiling water, does not differ materially from that proper for 
acute idiopathic cases of the same nature ; — it must be instant and 
energetic. It consists chiefly of depletion, local or general according 
to circumstances, counter-irritation, the exhibition of antimonial or mer- 
curial medicine, and the employment of a tepid demulcent gargle. 
Bronchotomy, as a last resource, should be performed as early as the 
necessity for it clearly exists, because the ultimate success of this ope- 
ration as of that for strangulated hernia, depends very much on the 
period at which it is instituted. 

The Second Degree of burn is characterized by the presence of vesi- 
cation, in addition to the erythematous rubefaction observed in the first. 
The vesicles form where the heat has been most intense, or longest ap- 
plied. Though generally formed immediately, or very soon after appli- 
cation of the caloric, they will continue enlarging, or new ones may be 
formed during the next twelve or eighteen hours, if the part has not 
been properly protected from irritation. The contained serum may be 
either clear or opaque, colourless or tinged with various shades of yel- 
low and red. Around them for some distance, the first degree of burn 
prevails, but the swelling and pain are here greater ; the latter, when 
the phlyctense are large and full, being accompanied with a feeling of 
tension. Such is the state of matters, when, as is most commonly the 
case, a hot liquid has produced the injury ; but, when it is occasioned 
by actual contact with a heated solid, the epidermis frequently adheres 
to it, and is torn off along with it on its removal. When this happens, 
the pain experienced from exposure of the denuded surface to the atmo- 
sphere, is exceedingly acute, and slight suppuration is almost inevitable. 
This suggests the propriety of not lacerating the vesicles ; or if, to 
relieve their tension, it be necessary to evacuate part of their contents, 
of making the opening as small as possible, and then preserving the 
cuticle otherwise entire until the surface beneath shall have no need of 
such protective covering. Under favourable circumstances, the detached 
cuticle dries, and shrivels up in a few days ; it then falls off, or may be 
removed, its place being supplied by a new layer of similar structure, 
as yet, indeed, more delicate, and of a reddish hue, but which soon 
assimilates its appearance to that of the original tissue. Even if slight 
suppuration occur, no mark is, after a time, discernible ; but if the 
purulent secretion be from any cause protracted, a scar or slight dis- 
figurement will ensue, which, however, with time and appropriate treat- 
ment, will ultimately disappear. 

The Local Treatment of the Second Degree of burn differs from that 
proper for those of the first grade, in so far only as the appliances to 



BURNS. 115 

the vesications are concerned. When produced, as this grade usually 
is, by scalding fluids, some parts covered by the clothes are generally 
more or less injured ; and in the removal of these the greatest possible 
care is requisite to prevent laceration of the vesicles, or the tearing away 
of the detached cuticle. If the vesication be slight, the treatment for 
the first degree may be instituted, taking every care that the elevated 
epidermis be preserved from injury. But if the subcuticular effusion be 
very great, the vesicles, as they become large and tense, should be 
punctured with a small needle. The evacuation of their contents in this 
way affords much relief; and if the fluid reaccumulate, it may again be 
discharged in a similar manner. Cold astringent lotions offer the most 
probable means of limiting the effusion ; but these may be counterindi- 
cated by various circumstances, which have already been sufficiently 
explained while speaking of the treatment of the first degree. Glyce- 
rine, mingled with an equal quantity of water, has lately been recom- 
mended as a topical application in burns of the first and second grades. 
It certainly has the property of keeping the part soft and moist for a 
long time. If the cuticle has been torn off, the raw surface, when large, 
is most effectually soothed and protected by the Linimentum Aquae Cal- 
cis ; or when small, by forming an artificial crust over it with mucilage, 
collodion, or the nitrate of silver, which being applied gently to the 
moist surface, coagulates the secretions, and thus forms a protective 
layer. Over the thin crust produced by the lunar caustic, a piece of 
gold-beaters' skin should be applied, to prevent its cracking and prema- 
ture detachment. The method of healing by incrustation is preferable 
when the prevention of scars is an important object, as it is when the 
face, neck, arm, or hand, especially in a female, is the seat of injury. 

The Linimentum Aquae Calcis, or Carron Oil, as it is popularly termed, 
has been employed indiscriminately over the whole of the burnt surface, 
whether blistered and denuded or not ; but its employment in this man- 
ner is attended, in some degree, with the same objection formerly offered, 
as prohibiting the application, over a large area, of a varnish imperme- 
able to aqueous moisture, namely, the checking or prevention of the 
cutaneous transpiration, which effect is, with justice, believed to increase 
the subcuticular effusion. The common turpentine liniment, composed 
of turpentine and resinous ointment, is objectionable on the same account, 
and is, besides, much too stimulant an application to the blistered sur- 
face. If the effusion in the vesicles become decidedly puriform, the 
raised cuticle must be freely incised, and the surface treated as an ordi- 
nary ulcer, should it continue to suppurate ; or the incrusting process 
may be tried, if the secretion of matter be scanty. 

The Third Degree of burn consists of cauterization of the epidermis, 
and the papillary or superficial layer of the dermis. Gunpowder explo- 
sions are said frequently to produce this grade ; and the skin in these 
cases is permanently tattooed, in many places, by the lodgment of black 
particles driven into it. In this grade, the part is usually charred at 
once, or it dies very soon. The eschars, in the slighter cases, are so 
thin as to resemble mere stain ; but in other instances, they may be 
half a line or more in thickness. They vary in colour, from grayish- 
yellow to dark-brown ; and, in consistence, from a moist and soft state, 



116 BURNS. 

to a dry and hard though pliant condition. When the consequence of 
a scald, they are usually of the lighter hue, and softer consistence ; and 
as, under these circumstances, the vitality of the part has not been in- 
stantaneously destroyed, the slough is frequently covered with dark 
vesications, the fluid contained in which is sanguineous, and of a red or 
brown colour. These are seldom found over an eschar which has been 
produced immediately by a solid of high temperature, because the slough 
thus formed is usually dry and hard. It is in that case also depressed, 
while the surrounding integument is corrugated and drawn in around it. 
When present, however, Dupuytren regarded these dark-coloured vesi- 
cations as extremely characteristic, indeed diagnostic, of this degree of 
burn. Occasionally, when produced by a solid body which has re- 
mained for some time in contact with the skin, or by a metal in the 
state of fusion, the cuticle, together with a thin layer beneath it, is torn 
off at the time, leaving the dermis exposed, and of a grayish colour, 
part of which dies subsequently, so that nearly its whole thickness is de- 
stroyed. Immediately around the charred portions of integument, the 
skin will be found to have suffered to the second degree, as exhibited by 
the limpid vesicles ; and still further off, to be merely affected with the 
erythema of the first. Dupuytren remarked that, while in every burn 
the pain is acute, it is much more intense when the skin is burnt only 
on its surface, than when the injury extends more deeply. Accord- 
ingly, the third degree of burn is found to be the most painful of any ; 
though some writers have stated it to be less so than the two preceding 
varieties. The danger to the constitution, also, is proportionately 
greater here than in these, — primarily, because the shock is greater and 
the pain more intense ; and secondarily, because the reparative powers of 
the system will be more largely taxed in this, than in the more superfi- 
cial injuries. So soon as the parts are quite dead, there is a remission 
of the pain for a few hours, until inflammation be established, and the 
process of separation commenced ; yet even during this interval, though 
the eschar itself be insensible to the touch, yet, from its thinness, a very 
gentle pressure on it, by being transmitted to the living and sensitive 
structure beneath, will excite acute pain. Upon the supervention of 
inflammation, there is a reaccession of pain, and it now continues very 
severe, until a short time after the sloughs have been thrown off; the 
period of which occurrence varies according to their thickness and the 
vigour of constitution, from four to fourteen days after the infliction of 
the injury. The removal of the sloughs must not be hastened by force, 
on account of the pain which such treatment would occasion. The re- 
maining sore is superficial, and generally cicatrizes rapidly. The result- 
ing cicatrix is at first redder than the surrounding integument ; but sub- 
sequently it becomes preternaturally white ; its surface depressed, 
smooth, and imperfectly papillated; or sometimes, when suppuration 
has been prolonged, it is marked by irregular lines, ridges, and corru- 
gated knots. The local result is, therefore, disfigurement. 

The Local Treatment of the Third Degree of burn, will be related 
along with that proper for the fourth, as the same case usually presents 
the characters of each. It will be sufficient, at present, merely to men- 
tion the formation of an artificial crust, by some of the methods already 



BURNS. 117 

described, as being very applicable when the eschar is thin, and most 
desirable when it is on exposed parts, as the cicatrix, obtained in this 
way, is much more perfect and similar to the original integument than 
that resulting from ordinary granulation. 

The Fourth Degree of burn is generally produced by the actual contact 
of a solid body at a high temperature. In this case an eschar is at once 
formed, comprehending the whole thickness of the skin, and frequently, 
also, the subcutaneous cellular tissue. It is here dark brown, or black 
in colour ; dry, hard, and leathery, yet brittle, in consistence ; and is 
quite insensible, pressure producing little or no pain, even in structures 
naturally the most sensitive, — the dermis being completely destroyed. 
Owing to the fluids having been thus almost instantaneously expelled 
from the carbonized integument, diminution of its bulk necessarily en- 
sues, both in its thickness, and its superficies. The eschar is conse- 
quently depressed below the level of the surrounding skin, and the latter, 
still more than in the third degree, is drawn in around it, exhibiting 
numerous puckered folds or corrugations radiating from the margin of 
disorganization. When the part dies more slowly from the violence of 
inflammatory reaction, the slough is softer and less depressed. Its thick- 
ness varies from one to three lines, being, for the same depth of destruc- 
tion, thinner in the hard and dry variety, because of its greater density 
and compactness, than in the soft and moist form, which is more loose 
and flabby in its texture. Receding from the point where the heat has 
been most intense, the three minor grades of burn are generally observa- 
ble ; that of the most superficial character occupying the most distant 
site. The pain is severe so long as the application of the cauterizing 
agent is continued ; but upon its removal it ceases, at least in that spot, 
for a few hours, during which time, little more than uneasiness may be 
felt in the part which bears the characters of this degree, because the 
structure which would have been most acutely sentient, had its vitality 
been preserved, has been at once destroyed. If, however, the neigh- 
bouring surface be affected in a more superficial manner, then the pain, 
already described as attendant on burns of the first three degrees, will 
be experienced. Even if the latter condition should not exist from the 
first, it will ensue, in the course of a few hours, and severe pain will 
then become developed from inflammation attacking the integument 
around. 

In three or four days, the parts beneath the slough have, from the 
same cause, become painful ; and both cause and symptom increase in 
severity during the first week, at the expiration of which period, or about 
the ninth day, their intensity begins to decline, and afterwards suffers a 
gradual diminution, which is contemporaneous with the establishment of 
the process of separation between the dead and living structures. The 
process of ulcerative absorption by which this is effected, having been 
described in another part of this work, need not be related here. The 
separation is effected during the third week after the infliction of the 
injury. Granulation now proceeds, in some cases, with sufficient activity ; 
but very often it assumes the indolent character, and is attended with 
profuse suppuration, when the surface is of large extent. The cicatrix, 
when at last completed, is, as before explained, much smaller than the 



118 BURNS. 

original destruction of integument ; it is permanently depressed, of a 
fibrous appearance, smooth unless cicatrization has been irregular ; pos- 
sessed of little common sensibility, and very liable to chafe and ulcerate. 
Thus by its appearance it constitutes, at least, a disfigurement ; while 
by its contraction, or adhesion to parts beneath, serious deformities may 
be produced, attended probably with much loss of motion. 

Previous to separation of the slough, or at least until that condition 
be considerably advanced, it is often difficult, if not impossible, to 
pronounce with certainty whether a burn be of the third, fourth, or 
even of the fifth degree ; especially in situations where the bones are 
but thinly covered by soft parts ; because the secondary sloughing, con- 
sequent on the inflammation, which attains its height about the ninth day, 
is frequently so extensive and profound, as to make an eschar, which at 
first seemed inconsiderable, become subsequently of very formidable 
dimensions. A knowledge of the manner in which the injury was pro- 
duced as regards the nature of the agent, and the mode and duration of 
its application, will assist in forming an idea as to how far the caloric 
may have penetrated. 

The following remarks will usually enable the primary amount of 
destruction to be ascertained. The present degree is distinguished 
from the third, by observing that in this grade, severe pressure on the 
eschar at an early period produces little pain ; while in the more super- 
ficial lesion, gentle pressure produces intense agony. As before ex- 
plained, there may be here also very acute pain from the commence- 
ment, owing to a superficial inflammation of the surrounding skin, and 
until pressure be actually made on the primary slough, the patient's 
sensations may not be so well defined as to inform him, that under it at 
least, there is little or no pain. From a burn of the fifth grade, the 
present degree is distinguished by its comparative want of sonoriety or 
resonance on percussing the eschar, which property, if present at all, 
can, from the thinness of the slough, exist only in a very slight degree ; 
while in a burn of the fifth grade, a distinctly sonorous sound is elicited 
from the eschar. Of course, in any case, where the slough is of the 
soft and moist description, percussion is useless, and could produce no 
distinctive sound. 

The Local Treatment of the Third and Fourth Degrees of burn com- 
prises four indications ; namely — -to regulate the amount of inflamma- 
tion ; to favour separation of the sloughs ; to assist the processes of 
granulation and cicatrization ; and to prevent, or in some cases, to 
modify, deformity. The first indication, which is to regulate the amount 
of inflammation, requires that its activity should be repressed when 
excessive ; and that when defective, local reaction should be promoted, 
because a certain amount of vascular action is necessary to effect the 
detachment of the eschar, and the subsequent cicatrization of the sore. 
To limit the inflammation, an elevated and relaxed condition of the 
part should be preserved. If it prove excessive, so as to threaten 
extensive secondary sloughing, local depletion may be required ; in 
estimating the necessity for which, the character and degree of the 
general symptoms of pyrexia will render valuable guidance. In robust 
and plethoric adults, in whom, from the injury being of small extent, 



BURNS. 119 

the system has been little depressed, the early abstraction of blood by 
leeches, may limit very considerably the impending destruction of tissue. 
These should be applied, when the collapse has quite worn off, as near 
as possible to the threatened part. Perhaps in a few rare cases a 
moderate general bleeding may be advisable, in order to restrain the 
local action ; but either form of depletion must be employed with the 
utmost caution, and in as sparing a manner as will suffice for the attain- 
ment of the immediate object in view; more especially when the 
amount of destruction has been great, because, as will afterwards be 
mentioned when describing the constitutional treatment, the powers of 
the system may be injudiciously weakened, when ere long it will have 
need of all its energies to carry on the work of reparation. 

On the other hand, when local and general reaction prove very tardy 
and defective, stimulant applications must be resorted to, in order, first 
— to excite a sufficient amount of local inflammation to throw off the 
slough ; and, secondly — through this medium to assist in rousing the 
system from collapse. For this purpose, the liniment composed of 
resinous ointment and turpentine, may be applied, and its stimulant 
properties regulated by varying, when necessary, the quantity of the 
latter ingredient. The manner of fulfilling the second indication, 
which is to promote separation of the slough, may vary a little under 
different circumstances. The warm water-dressing, consisting of cloths 
dipped in warm water, and covered with oiled silk to prevent evapora- 
tion and cooling, is usually the best appliance ; and if there be much 
pain the water may be medicated with opium. Light poultices answer 
the same purpose, but if large, they prove, from their weight, especially 
when on the trunk, distressing to the patient. If the inflammatory 
action be very weak the applications may be rendered stimulant by the 
addition of a metallic salt. No mechanical force must be employed to 
detach the eschars ; but if a large piece be loose except at one point, 
the greater portion of it may be cut off near the point where it is still 
attached. Occasionally matter forms under a part of the eschar, and, 
accumulating, gives rise to pain and tension. Fluctuation is perceptible 
at the part, and free incision of the slough is requisite to permit the 
escape of the purulent collection. The third indication, which is to 
promote granulation and cicatrization, comes into play immediately 
subsequent to the separation of the eschar ; when the usual treatment 
of granulating sores, as described while treating of the results of inflam- 
mation, is to be instituted. If there be much foetor, a weak solution of 
the chloride of zinc, or of soda, may be advantageously employed. 

If the sore lose its vigorous character, and become indolent, the part, 
especially when on an extremity, should be encircled with a lightly- 
applied bandage, which not only affords support, but, by the gentle 
pressure which it exerts, tends to prevent that flabby exuberance of 
granulation which is so liable to occur, and so certain, if it do occur, to 
retard cicatrization. 

It is proper here to mention that these injuries have been, and are 
sometimes at the present day, treated differently, by means of unctuous 
applications, by cotton, &c. The former of these are, however, by no 
means so cleanly as the water-dressing. The Unguentum Calamine, 



120 BURNS. 

and Oleum Palmae, are probably the least objectionable of them ; and it 
is advised to spread them thinly on lint, in which a number of small 
apertures have been made, so as to permit the free escape of matter 
from beneath the immediate dressing. The surface is also dusted over 
with vegetable charcoal by some surgeons, with the intention of thereby 
sopping up the profuse discharge. This is certainly not a seemly appli- 
cation ; and its use, when possible, had better be avoided, as the washing, 
required at each dressing to remove this substance, cannot be beneficial 
to the tender granulating surface. With regard to cotton, the application 
of which has been recommended in numerous layers, Professor Miller 
justly remarks, that in these severe burns, it " would speedily become 
soaked with the discharge, and either require frequent renewal or else 
prove a very hotbed of pestilential putrescence." 

The fourth indication, which is to prevent, or, in some cases, to modify 
deformity arising from the centripetal tendency of the structures around 
the burn, during and after cicatrization, is accomplished chiefly by pre- 
serving the parts in such an attitude that the tissues must be approxi- 
mated longitudinally as regards the long axis of the body, rather than in 
the transverse direction. For it will be observed that contraction of 
the cicatrix in the former way, will rarely produce deformity, though it 
may cause a degree of tension and stiffness ; while in the latter direction, 
serious impairment of motive function may readily be induced, from 
fixation of a joint even in a convenient attitude, or, what is more com- 
mon, in an extremely awkward and sometimes an absolutely dislocated 
position. In order to obviate this, the position of the part during the 
progress of cicatrization, and for some time after its completion, must 
be so ordered that it will oppose any such malposition of the joint impli- 
cated. The period of complete cicatrization may be thus somewhat 
deferred ; and if, during this delay, hectic should supervene, or prove 
more urgent, all opposition to Nature's own manner of cure must be 
desisted from, and subsequent measures trusted to, for the palliation or 
removal of any deformity which may have accrued from it. The con- 
traction can be moderated, and its direction regulated, in many situa- 
tions, where bandages would have no effect, as on the face, neck, and 
some parts of the limbs, by strips of isinglass plaster. As there is at 
the angles of commissure of the fingers and toes a great tendency to 
union of the opposed surfaces, the dressing must be carefully inserted 
between them up to the top of the fissure, and a turn of a bandage 
brought above, so as to exert a steady pressure on the part. Natural 
orifices must be kept, by appropriate mechanical means, from closure or 
constriction, during cicatrization in their neighbourhood. To prevent 
fixation of a joint, either from contraction of the tissues or from its 
long continuance in one attitude, passive motion must, in the latter 
stages, be cautiously instituted, and the exact position of the articulation 
varied a little from day to day. But in many cases the destruction has 
been so profound, or so extensive, that partial or complete loss of motion 
must inevitably ensue. In these instances, the joint, during treatment, 
must be preserved in that condition, as to flexion and extension, which 
will render the limb most useful if spurious anchylosis occur. This 
position, in the elbow, will be semiflexion, the forearm being bent nearly 



BUENS. 121 

to a right angle with the arm, and, in the knee, almost complete ex- 
tension. 

Amputation can seldom, if ever, be requisite in burns of the fourth 
degree, except in rare cases of very profuse and obstinate discharge 
from an extensive surface, in which the hectic proves imminent ; or 
when the soft structures over the bone are exceedingly thin, and are 
destroyed all around it, which occasionally happens in the fingers and. 
toes, a burn of the fourth class in these situations being locally as se- 
vere as one of the fifth grade in better protected parts. 

The Fifth Degree of burn consists of a disorganization — not only of 
the skin, but also of the subjacent soft parts to a variable depth, occa- 
sionally down to the bone itself. In this case the primary eschar 
when produced instantaneously, or at least rapidly, by incandescent 
or burning bodies, is black, depressed, and dry ; hard and sonorous on 
percussion. When the part dies more slowly, in consequence of the 
heat having been less intense, or applied for a shorter time, the slough 
is softer and more moist. It is quite insensible to pretty severe pres- 
sure until inflammation has set in, around and beneath it, when of course 
pain accompanies the vascular action, and is aggravated by pressure. 
During the violence of this reactional process, secondary sloughing of 
the tissues is very apt to occur. Arteries and nerves sometimes pre- 
serve their vitality in midst of the disorganization, for several days. 
More commonly, however, they perish at the same time with the other 
tissues, and if they happen to be large or important trunks, gangrene 
of the distal parts supplied by them may possibly be the result. The 
minor degrees of burn will usually be observed in more or less regular 
gradation, receding from the point where the heat has been most in- 
tense ; but independently of this source, pain becomes developed in a 
few hours after receipt of injury, from inflammation arising in the super- 
ficial parts immediately around the eschar ; and owing to the same cir- 
cumstance, during the second week, pain on pressure is elicited, gradu- 
ally extending from the circumference to the centre of the slough, as 
the vascular action increases beneath it. At the expiration of that 
period it begins partially to separate ; the most highly organized struc- 
tures being the first thrown off. In persons of bad constitution there is at 
this time danger of hemorrhage from arteries which have suffered solution 
of continuity, and which, owing to the vitiated state of the system, have 
not been occluded previous to the exposure of their extremities. Pieces of 
tendon remain frequently for several weeks undetached if not cut away ; 
and if bone have become necrosed, the exfoliated portions may not be 
thrown off for a much longer period. After an extensive injury of this 
severe character, the system requires some time to rally ; and it is not, 
in general, until two or three days after its occurrence that reaction is 
fully established. During, and for a considerable time after the sepa- 
ration of the slough, the suppuration is very foetid and abundant. 
Owing to the depth of the sore, healing advances very slowly. Muscles, 
tendons, and aponeuroses become adherent to each other, and contribute 
to form the cicatrix, which, when at last completed, is uneven and irre- 
gular, and effectually prevents any motion of the parts which have 
assisted in its production. The local results of this degree of burn may 



122 BURNS. 

be any of the different varieties of deformity or mutilation, attended by 
corresponding impairment or loss of function. 

The Local Treatment of the Fifth Degree of burn is precisely simi- 
lar to that already indicated as proper for like injuries of the fourth 
grade. Amputation is requisite in burns of this degree under the fol- 
lowing circumstances : — First, when upon separation of the slough, the 
interior of a large articulation, such as the knee or ankle, is laid open. 
Second, when the same result follows inflammation and abscess in its 
interior. Third, when a large . portion of bone is exposed on the de- 
tachment of the eschar, a condition which would induce extensive necro- 
sis. Fourth, when the loss otherwise is so great as to hold out little 
expectation of the sore healing ; or, if that should take place, of the 
limb, thus preserved, proving anything but an incumbrance to its pos- 
sessor. Fifth, at a later period, amputation may be called for to save 
the system from sinking beneath the hectic consequent on profuse and 
prolonged suppuration. 

The Sixth Degree of burn, which consists in the complete charring of 
the whole thickness of a part or limb, is easily recognised by the part 
thus incinerated being shrunken, hard, totally insensible to the severest 
pressure, brittle and distinctly sonorous on percussion. This primary 
eschar is black in colour ; and when produced at once by the limb being 
enveloped by metal in a state of fusion, the line of destruction pro- 
ceeds from the surface almost directly down to the bone ; but when the 
carbonization has been more slowly effected, the eschar proceeds more 
obliquely through the tissues, gradually penetrating more deeply as it 
approaches the point of actual contact with the burning body, at which 
part everything, including the bone itself, is involved in destruction. 
The secondary sloughing, however, brings both cases nearly to the same 
condition in this respect, and when the eschar is thrown off an irregu- 
lar and conical stump remains, of which the bone forms the most pro- 
jecting part, destined, ere cicatrization be effected, to die and exfoliate. 
The inflammatory reaction and separation of the slough gO on here in a 
similar manner ; but the latter requires a longer period for its accom- 
plishment than in burns of the fifth degree. Mutilation, the most severe 
of the local results, is the inevitable consequence of this grade. 

The Local Treatment of the Sixth Degree of burn consists usually of 
amputation. As the detachment of so thick an eschar is necessarily a 
work of considerable time, and as the stump then left is a very undesi- 
rable one, it is proper, unless counterindicated by the existence of some 
unusual circumstance, to amputate in every burn of this grade. This is 
to be done so soon as the collapse has gone off, and before the super- 
vention of the inflammatory, or, it might be, of the irritative fever, which 
otherwise would occur. 

The Constitutional Treatment of Burns comprises five indications; 
namely — to promote reaction ; to control and regulate its intensity ; to 
watch for and treat inflammatory affections of the internal organs ; to 
support the system under hectic and its complications ; and lastly, to 
remove mechanically, under certain circumstances, the cause of the 
hectic. 

The first indication then of general treatment is to promote reaction. 



BURNS. 123 

It is said that reaction is mainly brought about by the severity of the pain ; 
but this must only be when the pain is under a certain degree of intensity, 
for it is well known that this symptom, when excessively severe, itself 
exercises a powerfully depressing influence upon the heart's action. 
In many cases nature is able herself to rouse the system ; but if not, 
reactiou is to be promoted, when the patient can swallow, by the admi- 
nistration of some of the diffusible or more permanent stimuli, such as 
ammonia and brandy, in small and frequently-repeated doses. When 
the general surface and the extremities are cold, warmth should be 
applied, and, if practicable, sinapisms to the feet and pit of the stomach ; 
but the effect of these must be closely watched, lest they induce slough- 
ing. Opium has been recommended in large doses to diminish the pain, 
but this will tend to increase still further the cerebral congestion, which 
dissection has proved to be so common at this stage ; while, on the other 
hand, small doses will have no effect. The pain should in these cases 
be relieved, as far as possible, chiefly by topical remedies. When the 
collapse remains long, a warm and slightly stimulant enema may be ad- 
ministered, and repeated if necessary. 

This stimulant treatment, during collapse, must not, however, be car- 
ried too far ; and it is to be suspended so soon as signs of approaching 
reaction appear ; for otherwise, when that stage is fairly established, the 
persistent effects of a superabundant stimulation, or, in other words, its 
surplus would exaggerate the reaction, which would now require as active 
treatment in the opposite direction, and when subdued, if indeed not 
fatal, the system would be much more enfeebled than it would necessa- 
rily have been, had nature been left a little more to her own resources 
during her efforts to institute reaction. 

When, as stated before, premature and asthenic reaction comes on, 
marked by great irritability and nervous excitement, with a rapid, throb- 
bing, but feeble pulse, the exhibition of opium, in large doses, is attended 
with the most beneficial results. 

The second indication is to regulate the intensity of the reaction. 
When it proves excessive, without apparently any internal organ in 
particular being attacked, the antiphlogistic regimen will in general be 
sufiicient. In very few burns is bloodletting in any form required, or, 
indeed, in hospital practice, admissible ; but it may possibly be de- 
manded, in a few cases, to relieve the general inflammatory state of the 
system ; and at the same time, to moderate the local action, and thus 
limit the amount of secondary sloughing. In having recourse to these 
depletive measures, however, it must never be forgotten that, in all burns, 
except those of the first and second degrees, the powers of the system 
may at no distant day be taxed to their utmost to support suppuration, 
perhaps large in quantity, prolonged in duration, and secreted by an 
extensive surface. Accordingly, the slightest unnecessary lowering of 
the system will entail a still more profuse and protracted suppuration, — 
a still more tedious and possibly imperfect cicatrization. 

The third indication relates to the inflammatory affections of various 
organs which may occur. Their onset is often very insidious, and so 
must be watched for. They are to be treated in accordance with the 
ordinary medical principles applicable to each particular complication. 



124 BURNS. 

Bloodletting, when necessary, should be as moderate as possible, for 
the reason already specified ; and also on account of the well-established 
principle, that depletion cannot be borne to the same extent in secon- 
dary inflammations after a shock or injury, as in a primary or idiopathic 
affection of the same nature. 

The fourth indication is to support the system against hectic, and its 
complications. The appropriate treatment has been described when 
speaking of Hectic Fever. Over-stimulation must be guarded against, 
as this, equally with debility, impedes cicatrization by inducing flabby 
and exuberant granulation. The bed-sores, resulting from long-con- 
tinued pressure on the salient points of the back, sacrum, nates, and heels, 
exercise a very depressing effect. When threatened, a strong spirit- 
lotion is an excellent application ; or, if already formed, the part may 
be pencilled with nitrate of silver. Under the crust thus produced, the 
part, if relieved from further pressure, will readily heal. Arnott's 
water-bed, or a Mackintosh air-cushion, affords great relief by equaliz- 
ing the pressure over the whole decumbent surface. 

The fifth indication is to remove mechanically, when necessary, the 
cause of the hectic. Amputation, though frequently performed to fulfil 
a merely local indication, namely, the removal of an useless limb, is 
sometimes necessary for the sake of the constitution. Thus, if hectic be 
extremely urgent, the suppuration continuing very profuse, with a large 
surface still remaining for cicatrization, while the amount of the former 
is not satisfactorily diminished, nor the rapidity of the latter materially 
increased by remedies, then amputation must be performed in order to 
save life. 

Suppuration may be prolonged, and cicatrization delayed — from de- 
bility of system — from an extensive surface being involved — from bone 
having become necrosed — and from the opening of a large articulation, 
either by the sloughing of the tissues, or subsequent to inflammation 
and abscess in its interior. 

Affections of the cicatrix, — This structure is very liable to excessive 
contraction, to chafing, fissure, ulceration, and irritability. With regard 
to the first of these conditions, Professor Syme remarks that the cica- 
trix, when recent and still soft, may be gradually stretched. In an 
instance on the upper extremity, the successful extension was conve- 
niently effected by a strong iron-wire splint, which can be made in a 
few minutes, of any form, and when covered with soft washed leather is 
extremely useful. This splint admits of being straightened a little daily ; 
while it has sufficient rigidity to overcome the resistance of the cicatrix. 
When, however, the latter has become hard and unyielding, it cannot thus 
be stretched; and attempts to do so have led to great pain, inflamma- 
tion, and even gangrene of the lately-formed structure. Sometimes a 
few incisions, made through it, transversely to the desired line of exten- 
sion, may relieve the contraction ; but in many cases, nothing but a 
plastic operation will succeed. This consists in making an incision in 
the cicatrix, so arranged, as to permit the limb to be placed in an ex- 
tended and unconstrained position, in which it is to be maintained : a 
flap of integument, corresponding in form with the surface exposed by 
separated edges of the incision, is then dissected from some convenient 



BURNS. 125 

part in the neighbourhood; preserving, however, at one part its con- 
nexion undestroyed, by which it is to be nourished until fairly attached 
in the new situation to which it is now transferred, retention till that 
time being effected by sutures and plaster. The wound occasioned by 
its removal is treated on common principles, and the connecting slip 
divided, if necessary, so soon as perfect adhesion has occurred. An- 
other operation, which has been practised with success, consists in making 
two incisions in the form of the letter V, in the line of required exten- 
sion, embracing the scar and meeting at a point on the sound integu- 
ment below. The flap, consisting of the cicatrix with a narrow border 
of sound integument, is dissected up, from its apex towards the base ; 
till the limb can be extended, and is then laid down on its now somewhat 
altered situation ; the edges of the whole wound being brought together 
laterally. They are secured in the usual mode, and the lines of inci- 
sion are now found to resemble the capital letter Y. 

As the cicatrix, like all newly-formed structures, is very susceptible 
of absorption, the hard prominences, occasionally presented by it, can 
usually be removed by the steady pressure of some smooth and unyield- 
ing substance lightly applied ; but if this fail, they may be cut out. 
The chafing, cracking, and ulceration to which the scar is liable are fre- 
quently very distressing. Slight injuries suffice to abrade its surface ; 
it frequently cracks when much over-stretched during motion of the 
part ; and ulceration may follow either of these conditions. To guard 
against these states, all of which may likewise be induced or aggravated 
by cold, the cicatrix should if possible be kept well defended from exter- 
nal influences by a warm, soft, and fleecy covering, and by strict atten- 
tion to cleanliness. But the same conditions sometimes arise spontane- 
ously, as it were, or from some constitutional cause, which, if discovered, 
is to be rectified. When the fissures proceed from cold or other external 
irritation, glycerine, if it prove equally serviceable here, as in common 
cases of " chopped hands," will speedily effect a cure. 

The cicatrix, though little sensible to touch, is often morbidly sensitive 
to atmospheric changes, and is frequently the seat of uneasy sensations, 
which sometimes are so severe as to merit the name of neuralgia. These 
symptoms occasionally depend on the trunk or branch of a nerve being 
involved in the cicatrix ; but much more frequently no such cause can 
be discovered. In the former case, an operation for the excision or dis- 
entanglement of the implicated nerve could alone be expected to afford 
relief; and in the latter instance the usual treatment for neuralgia must 
be instituted. 



126 



CHAPTER V. 
FRACTURES. 

GENERAL DOCTRINES. 

A fracture, or solution of continuity of a bone, is said to be trans- 
verse, oblique, or longitudinal, according as it is at a right or an acute 
angle with, or parallel to, the long axis of the part of the bone in which 
it is situated. Where the condition of the bone, and that of the sur- 
rounding parts, is made the basis of arrangement, fractures may be 
divided into the following classes, namely — Simple, Compound, and 
Complicated fracture, Fracture with wound, Impacted, and Partial frac- 
ture. A fracture is said to be simple, when a bone is broken at one 
part without any coexisting injury of s,oft parts ; compound, or open, 
when there is an open wound of the superimposed parts, communicating 
with the fracture ; comminuted, when the bone is broken into several 
fragments ; complicated, when, together with the fracture, there is serious 
injury of the adjoining structures, as laceration of vessels, or of other 
important parts, or serious contusion of the superimposed tissues ; frac- 
ture with wound, when the wound does not communicate with the frac- 
ture ; impacted, when one fragment is lodged in the other; and partial, 
when the continuity of only part of the osseous fibres is interrupted. 
This last variety has been called by some bendi?ig with partial fracture, 
and by others green-stick fracture. Bending sometimes takes place 
without fracture ; but I have seen cases which I am convinced were 
cases of bending with partial fracture. 

The principal symptoms of fracture are pain, obvious deformity, preter- 
natural mobility, crepitus, and inability to move the affected limb ; but 
as the symptoms and causes of the particular fractures will be minutely 
described, it is unnecessary to refer to them under the head of general 
doctrines. 

The mode of union. — Baron Dupuytren made many experiments in 
dogs, rabbits, birds, and other animals, and, as the result of those expe- 
riments, he arrived at the conclusion that nature never accomplishes the 
union of a fracture without two successive deposits of callus, the one of 
which he names the provisional, the other the permanent. The first he 
believed to be perfected in from thirty to forty days — the production 
and complete organization of the otfrer, he believed, required eight, ten, 
or twelve months. 

Dupuytren arranged the phenomena, from the occurrence of the frac- 
ture to the exact and complete reunion, into five different periods or 
stages. 



FRACTURES. 127 

In the first stage, comprehending a period of eight or ten days, blood 
is extravasated into the medullary canal, between the fragments, and 
under the periosteum, raising up the latter from the bone for some dis- 
tance above and below the fracture. The medullary membrane becomes 
swollen and separated from the bone, and the periosteum is not only 
raised up from the bone, but it also becomes red, soft, swollen, and pre- 
ternaturally vascular. The fragments of bone may thus be said to be 
surrounded with blood, which not only fills the medullary canal and the 
space between the fragments, but also separates the latter from detached 
periosteum. This blood becomes absorbed, and liquor sanguinis is 
effused into the parts at first occupied by extravasated blood. 

In the second stage, comprising the interval between the tenth or 
twelfth day to the twentieth or twenty-fifth, the tumour of callus, as it 
is called by Dupuytren, is formed. The substance between the perios- 
teum and bone is converted into a structure like fibro-cartilage, and 
within the medullary canal there is also developed a fibro-cartilage, but 
the substance between the fragments retains the appearance of coagula- 
ble lymph. 

In the third stage, extending from the twentieth or twenty-fifth to 
the thirtieth, fortieth, or sixtieth day, according to age and strength, 
the fibro-cartilage between the periosteum and bone, and that within 
the medullary canal, are both converted into bone, the external forming 
a ring, or ferule, or clasp, and the internal a plug, or peg (cheville), 
filling up the medullary canal, and together constituting what Dupuy- 
tren calls the provisional callus. The external ring, embracing both 
fragments, and the plug within the medullary canal, constitute nature's 
provision for keeping the fragments in apposition and at rest. The 
substance between the fragments is, during this stage, changed into 
fibro-cartilage. 

In the fourth stage, extending to the fifth or sixth month, it is con- 
verted into bone, constituting what Dupuytren called the permanent or 
definitive callus. 

The fifth stage extends from the fifth or sixth month to the tenth or 
twelfth, during which the provisional or temporary callus, being no longer 
necessary, disappears, and the medullary canal is restored. 

Such are the views of Dupuytren on this interesting subject ; and, 
until lately, they were generally received as the correct explanation of 
the successive changes that take place, both in man and in the lower 
animals, from the occurrence of fracture until the injury is completely 
repaired. 

Mr. Paget, in his "Lectures on Repair and Reproduction," after in- 
juries, has brought forward different views from those which formerly 
prevailed regarding the repair of a fractured human bone, and has sup- 
ported his opinions by most conclusive evidence. His views on this sub- 
ject are in accordance with those of Mr. Stanley. An interesting and 
full account of them will be found in Mr. Paget's very instructive lectures, 
delivered at the Royal College of Surgeons of England, and published 
in the Medical Gazette for 1849. 

In reference to the description given by Dupuytren and others, of the 
examination of fractures in dogs, rabbits, birds, and other animals, Mr. 



128 FRACTURES. 

Paget remarks : — "All that is written in these accounts of external and 
internal, provisional callus and definitive callus, of the formations of 
cartilage and bone within the medullary tube, and beneath the peri- 
osteum, can be traced only, as it were, in rudiment in the fractures of 
the human bones. There is scarcely a specimen in the Museum of such 
provisional callus formed in the repair of a fractured human bone ; in 
nearly every case of such fracture, the material of repair is only inlaid 
between the broken surfaces, or between the adjacent parts of the frag- 
ments, and unites them by being fixed to both. In favourable conditions, 
this appears to be the usual mode of repair, even though the fragments 
of the broken bone be very much displaced. I have examined many 
more specimens, and find the same rule true ; namely, that in the ordinary 
repair of simple fractures in the human subject, the reparative material, 
or callus, is merely inlaid between the several fragments ; it fills up the 
interspaces between them and the angles, at which one fragment over- 
hangs another, but it does not encircle or ensheath them in the manner 
explained in the description of provisional callus ; nor is it in any con- 
siderable quantity, if at all, deposited either beneath the periosteum or 
within the medullary tube. In birds, dogs, and other ordinary subjects 
of experiments, the formation of a provisional, or, as it may perhaps be 
better called, an ensheathing, callus is usual." 

In evidence that the reparative material is placed not within and 
around the fragments, as an ensheathing, but between them, as an in- 
termediate callus, Mr. Paget not only adduces many fractures long after 
they have been completely healed, but as these might be deemed in- 
sufficient, he refers also to many recent specimens, at four, five, six, 
eight, nine, eleven, twelve, and sixteen weeks, and many others at un- 
known dates after the fracture. The only exceptions to the difference 
in the mode of repair of human bones and those of the lower animals, 
the only instances in the human subject in which, under ordinary cir- 
cumstances, provisional callus is formed, are in fractures of the ribs, and, 
although much more rarely, of the clavicle. 

According to Mr. Paget, other remarkable differences between the 
reparative process in man and in the lower animals, are — that in man 
no change of any importance occurs for a week or ten days, and the 
periosteum remains without being raised up or in any way particularly 
changed, except that it becomes slightly thickened and more vascular. 

The first new material produced is liquor sanguinis, which, according 
to Mr. Paget's observations, sometimes passes into perfect fibrous tissue, 
sometimes into fibro-cartilage, and, occasionally, although very rarely, 
into true cartilage. On this subject Mr. Paget remarks : — "In different 
specimens, or sometimes in different parts of the same, the reparative 
material may display — in one, fibrous tissue, with a few embedded cor- 
puscles, like the large nearly rounded nuclei of cartilage cells; in 
another, a less appearance of fibrous structure, with more abundant nu- 
cleated cells, having all the character of true cartilage cells ; and, in a 
third, a yet more perfect cartilage." 

Treatment. — The local treatment of simple fracture may be said to 
consist in fulfilling the four following indications : — first, bringing the 
fragments into a proper position, which is technically called reduction, — 



FRACTURES OF THE FOREARM. 129 

this should be done as soon as possible ; second, maintaining the parts 
in this position, or preventing any displacement; third, preserving the 
parts at rest until union be accomplished ; and fourth, obviating any 
untoward symptoms. The proceedings to be adopted for fulfilling these 
indications will be minutely explained in the description which will be 
given of the treatment suitable for each particular fracture. 

SPECIAL FRACTURES. 

FRACTURES OF THE FOREARM. 

Fractures of the forearm are more frequent than those of any other 
part of the body. Desault found, in the record which he kept of such 
cases, that they occupy the first place. Baron Dupuytren arrived at 
the same conclusion, as the result of his experience at the Hotel Dieu ; 
and Mr. Lonsdale also, who gives a table of nineteen hundred and one 
cases, found these to be the most frequent, and to form one-fifth of all 
fractures. 

In treating of these fractures, it is proposed to consider — First, The 
Classification, or arrangement of them ; Second, The Comparative Fre- 
quency of Cases belonging to each Class ; Third, The Symptoms and 
Nature of the Displacement peculiar to each Fracture ; and, Fourth, 
The Treatment proper to each Class. 

I. CLASSIFICATION. 

Fractures of the bones of the forearm may be divided into three 
classes : — 

1. Fractures of the radius, 

2. Fractures of both bones, and 

3. Fractures of the ulna. 

II. COMPARATIVE FREQUENCY OF CASES BELONGING TO EACH CLASS. 

From the following statistics of the Hotel Dieu, it appears that the 
cases belonging to the first class are more numerous than those of the 
second ; and the second more numerous than the third. Baron Dupuy- 
tren records, that in 1829, there were brought to the H6tel Dieu one 
hundred and nine fractures, of which twenty-three were of the forearm, 
and of these sixteen were of the radius alone, five of both bones, and 
two of the ulna alone : and that, in 1836, there were ninety-seven 
fractures, of which twenty-two were of the forearm ; and of these, six- 
teen were of the radius, four of both bones, and two of the ulna alone. 
These results are in accordance with the experience of most surgeons. 
But Mr. Lonsdale has given a table exhibiting a different result as to 
the comparative frequency of cases of the second and third classes. 
He found that of three hundred and eighty-six fractures of the fore- 
arm, one hundred and ninety-seven were of the radius alone, ninety-six 
of the ulna, and ninety-three of both bones. These statistics show that 
by far the greater proportion of fractures of the forearm, are fractures 
of the radius only; — a fact not difficult to be accounted for, when it is 
remembered that the radius may not only be broken by direct violence 

9 



130 FRACTURES OF THE FOREARM. 

applied to itself — to which it is also more exposed by its position as 
the outer bone, — but also by violence applied to the hand, which is sup- 
ported by the radius. 

Fractures of the right radius are more frequent than of the left. 
Baron Dupuytren found that of ninety-seven cases, fifty-nine were of 
the right, and thirty-eight of the left radius. 

III. SYMPTOMS AND NATURE OF THE DISPLACEMENT PECULIAR TO EACH 

FRACTURE. 

FRACTURES OF THE RADIUS. 

1. Situation. — Fractures of the radius may take place in any situa- 
tion ; they occur more frequently at the lower, than at the upper extre- 
mity, and still more frequently about the middle of the bone. M. Vel- 
peau states that fracture of the ulna is found more frequently below 
than above, and of the radius, on the contrary, more frequently above 
than below. This he probably inferred from the circumstance that the 
lower extremity of the ulna is smaller than the upper, while the reverse 
is true with regard to the radius. Most surgeons, however, maintain 
that fractures of the radius are not so frequent at the upper as at the 
lower extremity. 

Fracture at the neck is an exceedingly rare accident. Sir Astley 
Cooper says : — " This fracture I have heard mentioned by surgeons, as 
being of frequent occurrence, but there must be some mistake in the 
statement, for it is an accident which I have never seen ; and if 
instances ever present themselves, which I do not mean to deny, they 
must be very rare." M. Velpeau's statement with regard to the ulna 
agrees with general experience. 

2. Causes. — The radius is fractured by violence, applied either directly 
to the bone itself, or indirectly through the hand ; for instance — when 
a person falls on the hand, the radius receives the shock from the hand, 
the upper part receiving the whole momentum of the body from the 
humerus, while the lower part rests against the hand upon the ground ; 
the radius bends, and, if the force be sufficiently violent, gives way — 
generally near the middle. This fracture is more frequently occasioned 
by a fall on the palm than on the back of the hand. Out of fourteen 
cases, Baron Dupuytren found that three were owing to falls on the back 
of the hand, and eleven to falls on the palm. Cruveilhier, therefore, 
was mistaken in believing that the radius could not be fractured by a 
fall on the back of the hand. 

3. Symptoms. — Pain, loss of the power of voluntarily effecting the 
movements of pronation and supination, and the prone position of the 
hand, are indicative characters of this injury. There are also other 
symptoms which deserve attention, namely, a motionless condition of the 
head of the bone during pronation and supination, crepitus, a diminu- 
tion of the transverse measurement of the forearm occasioned by the 
fractured portions falling into the interosseous space, and projection of 
the fractured ends on the back of the forearm, when the hand is very 
forcibly bent. If the fracture be in the middle, or in the lower two- 
thirds, it may be felt by the finger. 

The motionless condition of the head of the radius may best be ascer- 
tained by the surgeon grasping the upper part of the forearm with one 



FRACTURES OF THE FOREARM. 131 

hand, having his thumb firmly pressed on the head of the bone, while 
with the other hand he takes hold of the hand of the patient on the sus- 
pected side, and forcibly performs pronation and supination. A motion- 
less condition, under these circumstances, indicates fracture — mobility 
is a proof of integrity. This is a most useful guide to diagnoses when 
the fracture is in the upper part, in which case, from the bone being 
covered by muscles, the other symptoms are more obscure. 

Crepitus, which can best be discovered during the above method of 
examination, is a sure symptom of fracture. It has been called crepitus, 
or hard crepitus, to distinguish it from a soft crackling sensation some- 
times produced by effusion into the soft parts. The absence of crepitus, 
however, will not prove the non-existence of fracture ; for crepitus may 
be prevented altogether by the presence of muscular fibre between the 
broken extremities, or it may be rendered not very perceptible, in the 
first instance, by the effusion of blood, or, at a much later period, by the 
secretion of lymph. 

Diminution of the transverse measurement of the forearm, occasioned 
by the fractured portions falling into the interosseous space. This 
symptom is most apparent when the fracture is near the middle ; it can 
be increased by pressing the bones near the fracture, or by forcibly 
bending the hand to the radial side of the forearm. 

When the fracture is in the upper third, this symptom is not very 
perceptible. When the fracture is very near the wrist, the fractured 

Fig. 17. 




portions often occasion such a pressure upon the tendons as to prevent 
the motions of the fingers, and sometimes the swelling from effusion into 
their sheaths gives the appearance of a dislocation. The accompanying 
sketch, from Liston, is very characteristic of fracture near the wrist. 

4. Position of the fractured portions. — If the fracture be near the 
middle of the bone, the part above the fracture remains in its natural 
position ; the part below is drawn too far backwards or forwards, follow- 
ing the movements of the hand when pronated or supinated, and can 
only be kept in a line with the upper part when the hand is midway 
between pronation and supination ; it is also drawn too near the ulna 
by the pronator quadratus muscle ; hence arises the diminution of the 
interosseous space. When the radius is fractured at its neck, the infe- 
rior part is drawn upwards, inwards, and forwards, by the biceps mus- 
cle, while the head and fractured neck are drawn slightly outwards by 
the supinator radii brevis. 

FRACTURE OF BOTH BONES. 

Causes. — Fracture of both bones may be caused by a blow, or by a 



132 FRACTURES OF THE FOREARM. 

heavy body passing over the forearm, — in which cases the bones are 
usually fractured in the same situation ; or by a fall on the hand, when 
the radius, which in the first instance receives the whole shock, is frac- 
tured, and the ulna, to which the shock is thus transferred, gives way 
likewise. In the latter case the bones are not necessarily fractured in 
the same situation. 

There is a difference of opinion among surgeons respecting the usual 
situation of the fractures, when both bones are broken ; some supposing 
that they are generally in the same situation, while Velpeau and others 
maintain the contrary opinion. In explanation of this difference it may 
be stated, that the fractures, if produced by violence applied to the hand, 
will not be in a line, as the weakest part of each bone will give way ; 
but if the fractures be the result of direct violence, they will in every 
probability be in the same situation. 

Symptoms. — The symptoms are, — pain increased on moving the parts, 
loss of the power of pronation and supination, tumefaction or some un- 
natural appearance, for the most part an apparent decrease of the dia- 
meter of the forearm from side to side by the diminution of the inter- 
osseous space, and increase of the antero-posterior diameter by the 
muscles being forced out from between the bones ; angular deformity, 
apparent on raising the forearm ; mobility in a part which ought to be 
inflexible ; and crepitus, which can generally be made very perceptible 
by the surgeon giving a rotatory motion to the hand. The inter- 
osseous space may be still further diminished by compressing the bones. 
The forearm is generally semi-flexed, and there is but little shortening 
of the limb. 

State of the parts. — The pronator quadratus muscle draws the under 
parts of the two bones towards each other, and the pronator radii teres 
draws the part of the radius into which it is inserted towards the ulna ; 
this diminishes the transverse diameter, while the consequent pressing 
out of the muscles from between the bones occasions the increase of the 
antero-posterior. 

Fig. 18. 




The parts of the bones below the fracture can be made to point 
towards the parts above, only when the hand is in a straight line with 
the forearm, and midway between pronation and supination. 



FRACTURE OP THE ULNA. 



Three fractures of the ulna are met with, namely, of the shaft, and of 
the olecranon, and coronoid processes. 

Fig. 18. From Listen. 



FRACTURES OF THE FOREARM. 166 

Fractures of the processes present peculiar symptoms, and require 
particular methods of treatment ; we shall, therefore, delay the consi- 
deration of them, until after the description of the treatment proper for 
the other fractures of the forearm. 

FRACTURE OF THE SHAFT OF THE ULNA. 

Causes. — This fracture is almost always caused by violence directly 
applied to the bone, as by a blow or a fall on the inner side of the fore- 
arm. 

Symptoms. — The existence of this fracture can be easily discovered, 
by drawing the finger along the inner part of the ulna, when, from the 
superficial situation of the bone, an irregularity caused by the fracture 
is perceptible. There is a depression at the seat of the fracture, and 
the part below it is too near the radius. 

Crepitation is usually perceptible on moving the under part backwards 
and forwards ; and sometimes the long axis of the hand is not in a line 
with the long axis of the forearm, but is drawn inwards. 

State of the parts. — The fracture is generally in the under part of the 
bone, where it is most slender, and exposed to injury from its superficial 
situation. The position of the fractured parts is as follows : — the part 
above the fracture is preserved in its natural situation by its connexion 
with the humerus, whereas the part below is drawn towards the radius 
by the pronator quadratus. 

IV. TREATMENT OF THE THREE CLASSES OF FRACTURES OF FOREARM. 

The treatment of all these fractures consists of two parts ; the pro- 
curing and maintaining coaptation. This is procured by bending the 
forearm at right angles to the arm, and placing the hand midway be- 
tween pronation and supination ; then using slight extension, if neces- 
sary, and pushing back the protruded muscles between the bones. To 
maintain coaptation, we must call in the aid of both attitude and mecha- 
nism. 

Attitude. — In each class of fractures the forearm ought always to be 
at a right angle with the arm, that the muscles of the arm may be uni- 
formly relaxed ; and the hand ought always to be placed midway be- 
tween pronation and supination, that is, with the thumb upwards and 
the little finger downwards. If this be neglected, the fractured portions 
will unite so as to form an angle with each other ; and the consequence 
will be the loss of the power of supination, if the hand be kept in a state 
of pronation, and of the power of pronation, if it be supinated. The 
only variation of attitude in the different classes of fractures is in the 
relative position of the hand and the long axis of the forearm : in frac- 
tures of both bones the long axis of the hand should be in a line with 
the long axis of the forearm; in fractures of the radius, the hand should 
be depressed ; and in fractures of the ulna slightly elevated. 

The object aimed at in these peculiarities of position is to prevent the 
diminution of the interosseous space ; which is accomplished, in fracture 
of both bones, by uniformly extending the muscles connected with the 
radius and ulna ; in fracture of the radius, by extending the muscles 
attached to the outer side of the radius, and in fracture of the ulna by 



134 FRACTURES OF THE FOREARM. 

the extension of those on the inner part of the bone ; and these condi- 
tions of the muscles are produced by the above-described attitudes of 
the hand. The following directions exhibit at one view the attitudes to 
be observed : — 

1. Bend the forearm at a right angle with the arm. 

2. Keep the hand midway between pronation and supination. 

3. In fractures of both bones, keep the hand in a line with the long 
axis of the forearm. 

4. In fractures of the radius, -depress the hand. 

5. In fractures of the ulna, raise the hand. 

Mechanism. — Various appliances have been used to preserve the parts 
at rest, and in apposition. Some surgeons use paste-board splints, 
softened in hot water, and then moulded to the forearm ; some employ 
splints composed of several parallel pieces of wood secured together by 
a piece of linen or leather, while others make use of two wooden splints, 
slightly concave on one side and convex on the other. Baron Boyer 
recommends that a small oblong pad should be applied between the con- 
cave surface of each splint, and the forearm, in order more effectually 
to press in the muscles, and to preserve the interosseous space. But if 
the splints be applied closely, the pressure in the direction of the antero- 
posterior diameter will be sufficient ; nor will any padding be requisite, 
except a little cotton to prevent the pressure from irritating the skin. 
In fracture of a single bone the splints should extend only to the wrist ; 
but when both bones are broken, one of the splints should reach to the 
fingers, that the hand may be kept in a line with the long axis of the 
forearm ; — the longer is usually applied to the front of the forearm. 

To preserve the mechanism in its proper situation various means have 
been employed. The common roller and starch-bandage are both ob- 
jectionable, inasmuch as they tend, by pressing the radius and ulna toge- 
ther, to diminish the interosseous space ; besides which they keep up a 
degree of heat about the part, and create trouble in taking off the splints, 
which must occasionally be done to ascertain whether the part presents 
the desired appearance. The loop-bandage is not liable to the same ob- 
jections, but the most convenient and elegant manner of treating these 
fractures is to use the wooden splints, retaining them in the proper posi- 
tion by the buckle-bandage. Two or three may be used, and the fore- 
arm should be kept in a sling. 

DIRECTIONS AS TO MECHANISM. 

1. In fractures of one bone, apply two splints of equal length, not 
extending beyond the wrist. 

2. In fractures of both bones, use two splints of unequal length, the 
larger being applied to the front of the forearm, and reaching to 
the ends of the finger ; the other need not be extended beyond the 
wrist. 

The objects aimed at by treatment in these fractures are to obtain 
coaptation, to preserve the interosseous space, and to keep the parts at 
rest in a proper position. For the attainment of these ends, attitude 
and mechanism are both necessary ; the former should be used from the 
very beginning of treatment ; but the application of mechanism should 



FRACTURES OF THE FOREARM. 135 

be delayed until either the danger of inflammation supervening is over, 
or the inflammation, if it has already taken place, has been subdued. 

[Dr. J. R. Barton, of this city, has called the attention of the profes- 
sion to the treatment of fractures at the lower end of the radius. 

Two splints are recommended, which should reach beyond the ends of 
the fingers. But previously to this application, one compress should be 
adjusted upon the lower fragment, and another against the lower extre- 
mity of the upper fragment. 

Owing to the proximity of this fracture to the wrist, it is found that 
the stiffness of the joint is very great ; and that notwithstanding the 
surgeon's efforts at passive motion, considerable inconvenience frequently 
results. Dr. Henry Bond, of Philadelphia, has recently read a paper 
before the College of Physicians, giving an account of a new splint for 
this fracture. 1 

He objects to the present mode of treatment of this fracture, on the 
grounds that the muscles are rendered tense, and that, in order to pre- 
vent derangement of the fragments, the hand must necessarily be tightly 
bandaged in a constrained position, and that pressure on the bursae of 
the tendons of the fingers must increase the danger of that protracted 
or permanent rigidity that often renders the hand and fingers unsightly, 
inconvenient, or useless. 

" The muscles that act on the hand are least tense, or most in repose, 
when the hand is inclined backwards, so that the metacarpe forms a 
considerable angle with the forearm, 2 when it is also inclined inwards 
towards the ulnar side of the arm, and when the fingers are moderately 
flexed. In this case, it will be perceived that the longitudinal axis of 
the forearm, if prolonged, would not correspond with that of the hand, 
but would pass through, or very near, the point where the thumb and 
index finger most easily and naturally meet. Thus, in the innumerable 
manipulations with the thumb and fingers (as with a pen, pencil, 
button, needle, money, &c, &c), their points most easily and natu- 
rally meet in this axis of the forearm. This will be found to be the 
position of the hand, when it hangs by the side with all the muscles re- 
laxed. 

" But if the hand can be placed and retained in the unconstrained 
natural position above mentioned (to say nothing of the better chance of 
escaping permanent stiffness), in the first place, the unsightly deformity 
will be avoided ; and in the next place, the hand will not entirely have 
lost its uses. For the hand, thumb, and fingers being placed very 
nearly in the position of their most frequent uses, the interossei, the 
lumbricales, and the several short muscles of the thumb will, by causing 
only a very limited motion, enable the hand to perform very many of its 
useful functions." 

In order to fulfil these indications, Dr. Bond has devised a splint and 
dressing. A splint is cut out of a light thin board, of the shape of that 
represented in Fig. 19. The particular size and form can be obtained 
from the profile of the sound forearm and hand, when placed in its 
natural situation, the hand inclining towards the ulna. The lower end 

1 Trans. Coll. Physicians, Jan., 1852. 

2 Malgaigne calls this, " la flexion habituelh de la main en arriere.'" 



136 



FRACTURES OF THE FOREARM. 

Fig. 19. 



of the splint should be cut obliquely and reach to the second joint of 
the fingers, so as to allow them to be flexed. 

This splint is then to be carefully covered with muslin or sheeting, 
which is to be fastened by tacks or glue , so that the roller can subse- 
quently be applied with little danger of its slipping, and if necessary 
pins may be used to prevent its derangement. 

A carved and rounded block (B, Fig. 20) is nailed or screwed to the 
extremity of the palmar surface of the splint, of such a size and form as to 
retain the hand in its habitual inclination backwards, and to give the fingers 

Fig. 20. 




that moderate flexure which most relieves the muscles from tension ; 
and also that position, which, if stiffness should result, will not only save 
the hand from a most inconvenient and ungraceful deformity, but will 
reserve to it the power of performing very many of its most frequent 
and useful functions. 

A piece of binders' board, wider than the splint, is to be tacked to its 
palmar surface, and the projecting edges (D, Fig. 20) bent up so as to 
form a kind of box for the lodgment of the arm. The pasteboard is not an 
essential part of the splint, but may contribute to the comfort of the 
patient. The splint is then to be lined with flannel, which should also 
cover the block. 

Two compresses, of the proper form and material, constitute the 
remainder of the dressing, unless the fracture be far above the wrist, 
and then a dorsal splint may be necessary to preserve the interosseous 
space. — Ed.] 

FRACTURE OF THE OLECRANON PROCESS. 

Causes. — This, which is by no means an uncommon fracture, is usually 
caused by a blow or a fall upon the elbow, and sometimes, although very 
rarely, by violent contraction of the triceps extensor cubiti muscle. 

Varieties. — This fracture may be, in direction, either transverse or 
oblique, and in situation, at the base, middle, or apex of the process. 
Transverse fracture in the middle of the process is the most frequent, 
both as to situation and direction. 



FRACTURES OF THE FOREARM. 137 

Symptoms. — An unnatural hard swelling, caused by the olecranon, 
in the under and back part of the humerus, sometimes half an inch 
above the joint, and sometimes two inches from the part from which it 
is broken off; the distance is increased by bending the forearm, or by 
a voluntary effort on the part of the patient to accomplish extension of 
the joint. This swelling can easily be moved from side to side, but it 
cannot be pressed downwards without difficulty, especially if the extre- 
mity be in such a position as to keep the triceps on the stretch. 

Bulging of the triceps above the hard tumour is a good diagnostic 
symptom. 

An interspace on the back part of the joint between the olecranon, 
and the extremity of the ulna ; this space is increased by a voluntary 

Fig. 21. 




effort on the part of the patient to extend the elbow, which merely 
draws up the broken fragment ; or by the surgeon taking hold of the 
forearm and bending it, and it is diminished by extending the forearm. 
The surgeon, on pressing his finger into the interspace, feels as if it 
were sinking into the joint. 

Loss of the power of extending the limb is another symptom ; and 
the voluntary effort to do so causes pain, and merely draws up the ole- 
cranon. In some cases the power of extension is not entirely lost. 
This can only happen when the expansion of the triceps is not so 
completely destroyed as to disconnect the process from the rest of the 
bone. Sir James Earle has recorded a case in which the loss of exten- 
sion did not take place until the sixth day, when it was sudden, and 
attended with sudden flexion of the forearm. 

Crepitus may be discerned, if the extremity be very violently ex- 
tended, and the parts pressed together with considerable force ; but 
attempts to do this occasion great pain. 

The forearm is usually half bent, and there is often great swelling 
about the joint, from increased secretion of synovia, and frequently 
ecchymosis to a considerable extent ; but these last two symptoms will 
vary according to the degree of violence by which the accident was oc- 
casioned. 

Mode of union. — Reunion in this fracture is almost always by a 
ligamentous substance, the length of which will vary according to the 
distance of the broken parts from each other. It is very desirable to 

Fig. 21. From Liston. 



138 FRACTURES OF THE FOREARM. 

have it as short as possible, because, in proportion to its length, the 
arm will be weakened. When the interspace is short, the ligamentous 
substance is firm, strong, and short ; but if it be long, there may be 
openings through it, so that the reunion will be kept up by ligamentous 
cords. On account of the difficulty of preserving the parts in apposition, 
no other than a ligamentous union is generally to be expected. In some 
cases, however, when the fracture had happened very near to the shaft 
of the ulna, Sir Astley Cooper has known the union take place in the 
living subject by bone ; but it is so rare an occurrence that it is scarcely 
to be hoped for. It seems evident from the following experiments, made 
by Sir Astley Cooper, that the difficulty of preserving the parts in ap- 
position, is the obstacle to osseous union. " The integuments having 
been drawn laterally and firmly over the end of the olecranon in a dog, 
I made a small incision, and placed a knife, on the middle of that pro- 
cess, in a transverse direction ; on striking it with a mallet, the bone 
was readily cut through, a separation directly took place by the action 
of the triceps muscle, adhesive matter was effused, and, when I examined 
the limb about a month after, I found the bone united by a strong liga- 
ment. I broke the olecranon in the same way in several rabbits ; blood 
was, in these experiments, first thrown out, and then adhesive matter 
filled up the space of separation, which subsequently became ligamen- 
tous, and gradually firmer and firmer, as the time was protracted between 
the experiment and the time of the examination. As I found the liga- 
ment was formed in each of these experiments, I was anxious to learn 
whether the olecranon could be made to unite by bone, if a longitudinal 
fracture were produced with but slight obliquity, so that the broken por- 
tions might still remain in contact ; and I found that, under these cir- 
cumstances, the osseous union speedily took place. Therefore this bone, 
like the extremity of the os calcis, when it is broken off, is detached 
by the action of the muscles, and ligamentous union ensues from want 
of adaptation." 

Treatment. — The principal indications in the treatment are — 

First, If there be much inflammation and irritation at first, to delay 
all mechanical applications, until they are subdued by leeches, evapo- 
rating lotions, purgatives, and other remedies, which should be employed 
with activity proportioned to the violence of the symptoms. 

Secondly, To maintain the fractured surfaces as close together as 
possible by the judicious position of the limb, and the absolute inaction 
of the triceps muscle aided by mechanical appliances. 

The extremity must be kept very much extended, and for some time 
this can best be done by keeping the patient in bed. It is necessary not 
only to keep the forearm extended, but also to bring back the arm, that 
the shaft of the ulna may be brought as near as possible to the attach- 
ments of the triceps, both to the humerus and scapula, so that the least 
obstacle may be offered by that muscle to the bringing down of the 
olecranon. 

Sir Astley Cooper recommends that the parts be kept in apposition, 
by placing tape or slips of linen longitudinally on each side of the joint, 
and applying over these a roller round the arm, immediately above and 
below the fracture only, and then tying the ends of the slips above the 
fracture to those below, so that the rollers, under which they pass, are 



FRACTURES OF THE FOREARM. 139 

brought nearer to each other, and the detached fragments may be thus 
kept in the desired position. 

Thirdly, to preserve the joint at perfect rest ; and for that purpose 
a straight splint should be applied in front, and retained by a suitable 
bandage. 

Fourthly, To begin passive motion of the joint in the course of a 
month, and for this purpose the splint is to be removed ; but as there is 
great danger of weakening and lengthening the newly-formed bond of 
union, all attempts at motion must be made with the greatest care. 

The above plan of treatment, in which the extended position and 
straight splint are employed, is that which is recommended by Sir Ast- 
ley Cooper, and practised by most British surgeons ; but it is objected 
to by Desault, Camper, and others, who recommend that the forearm 
should be kept midway between semiflexion and complete extension, and 
that this position should be preserved by means of an angular splint. 

Desault and Camper, the advocates of this method, give the following 
reasons for preferring it to that usually practised by British surgeons. 

1st. The method which they recommend will bring the fractured parts 
more in a line with each other. The brachialis anticus, in its way from 
the sides of the deltoid impression to the coronoid process, passes over 
the eminence formed by the lower extremity of the humerus ; and they 
say that the muscle, being put violently on the stretch, will draw for- 
ward the ulna, if the olecranon be fractured near its base, and, conse- 
quently, the ulna and the broken fragment will not be in a line with 
each other, the shaft of the bone being brought too far forward. This 
objection does not apply to the method recommended by the French. 

2dly. They also state that in the attitude recommended by the Bri- 
tish surgeons, the broken parts can only be made to touch each other 
posteriorly, so that they form a retiring angle opening into the joint, 
into which, therefore, the substance effused for uniting the fractured 
portions will be thrown, and thus the future movements of the joint be 
permanently impeded ; whereas, in the attitude of Desault, the two 
portions will meet in front, and form a retiring angle directed back- 
wards, and thus the future movements of the joint will be unaffected by 
the new formation. 

FRACTURE OF THE CORONOID PROCESS. 

Causes. — This is a rare accident, but two cases are recorded by Sir 
Astley Cooper, and one by Mr. Liston. Of the two instances recorded 
by Sir Astley, one was the case of a gentleman, who fell on his hand 
while the arm was extended. The coronoid process, being driven against 
the humerus, received the shock, and gave way. The other instance 
was found in a subject brought to the dissecting-room at St. Thomas's 
Hospital, and the cause was unknown. The case mentioned by Mr. 
Liston, was that of a boy eight years of age, and the fracture was occa- 
sioned by his hanging for a long time by his hands, from the top of a 
high wall, being afraid to drop down. 

Symptoms. — The forearm is extended, and the ulna projects back- 
wards ; but when the forearm is bent and brought forward, which is 
easily done, the deformity disappears ; the limb, however, again becomes 
extended, and the deformity returns, when the force employed to bend 



140 FRACTURES OF THE HUMERUS. 

and bring forward the part is removed. The isolated process is felt in 
front of the joint, or higher up, according to the state of contraction of 
the brachialis muscle inserted into it. 

Treatment. — The objects to be aimed at by treatment are, — to relax 
the brachialis anticus muscle, to preserve the parts at rest, and to keep 
the isolated fragment as much as possible in apposition with the part 
from which it has been detached. These objects may be best attained, 
by keeping the forearm very much bent, and applying angular wooden 
splints, very well padded, or pasteboard splints moistened in hot water, 
and moulded to the elbow. 

This treatment should be continued for about a month, and passive 
motion should then be employed ; but this must be done with the great- 
est caution, lest the ligamentous substance, which reunites the parts, 
should become weakened and lengthened. 

FRACTURES OF THE HUMERUS. 

These injuries, according to Mr. Lonsdale, form about one-sixteenth 
of all fractures, so that they occur less frequently than the correspond- 
ing injuries of some of the other bones. Of one hundred and eighteen 
cases of fracture of the humerus, mentioned by Mr. Lonsdale, eighty- 
nine were of the shaft, sixteen of the condyles, and thirteen of the sur- 
gical neck. 

That the description of the different fractures of this bone may be 
more distinct, it will be convenient to arrange them in the following 
classes : — 

1. Transverse fracture of both condyles. 

2. Oblique fracture of either condyle. 

3. Fracture of the under third of the shaft. 

4. Fracture at the middle of the humerus. 

5. Fracture below the insertions of the three muscles into the margins 

of the bicipital groove. 

6. Fracture above the insertions of the three muscles into the margins 

of the bicipital groove, or, as it is called, fracture of the surgical 
neck of the humerus, a name given to all that part between the 
insertions of these three muscles and the tuberosities. 

7. Fracture of the anatomical neck of the bone. 

The bone may be broken in any part of its length, but all its fractures 
may be included in one or other of the above-named classes. 

I. TRANSVERSE FRACTURE OF BOTH CONDYLES. 

Symptoms. — The symptoms of this fracture are, an unnatural promi- 
nence behind the joint ; immediately above this, an unnatural foss or 
depression ; and preternatural, shortening of the front of the forearm. 
These three symptoms are common to this fracture and dislocation back- 
wards of the radius and ulna ; but there is in fracture, the following 
sure diagnostic guide ; if the arm be fixed, and the forearm be drawn 
in the line of displacement, the symptoms disappear ; but they return, 
as soon as the extending force is removed. If the arm be fixed, and the 
forearm pressed backwards and forwards, or if it be rotated, crepitation 
may be perceived ; and, if the arm be raised, and the forearm forcibly 
depressed, an angular deformity will be observed. 



FRACTURES OF THE HUMERUS. 141 

Desault and others mention frequent cases of this fracture, in which 
the condyles were not only broken off by a transverse fracture from the 
rest of the humerus, but also separated from each other by a vertical 
fissure. In these instances, we have in addition to the before-named 
symptoms, a still greater mobility of the parts, increased deformity, the 
bulging out of the joint laterally augmented by pressing in the direction 
of the longitudinal fissure. 

State of the fractured portions. — In simple transverse fracture, the 
condyles are drawn backwards ; in transverse fracture of both condyles 
with a longitudinal fissure between them, they are drawn backwards, 
and very slightly separated from each other. In this latter case the 
humerus is separated into three pieces. 

Treatment. — Bend the forearm at a right angle to the arm, draw it 
forward until the parts be brought forward into their proper places and 
into apposition, and preserve them in this condition by applying a few 
turns of a roller round the lower part of the arm and the upper part of 
the forearm, and by employing two wooden splints, — one, straight, to 
be placed in front of the humerus, the other composed of two parts at a 
right angle with each other, the upper part to be placed behind the hu- 
merus, and the lower part below the forearm ; both splints to be retained 
by buckle bandages. Evaporating lotions should be applied, and the 
extremity kept in a sling. 

The above is the treatment recommended by Sir Astley Cooper ; it 
should be continued in the case of an adult for about a month, and with 
a younger patient for nearly three weeks, after which time passive mo- 
tion should be tried, that the joint may recover its power of moving. 

I have treated this fracture very successfully by means of Weiss's 
splint, which is a most convenient apparatus for the purpose, inasmuch 
as it admits of the elbow being slightly moved when that is thought to 
be judicious, without the necessity of taking off the splint. 

Desault has recommended two angular splints with joints, and some 
Italian surgeons apply two angular splints, the one before and the other 
behind the joint. If the condyles be separated, care must be taken to 
keep up lateral pressure. 

Although in some instances this injury is so seriously complicated 
with laceration and contusion as to make it necessary to remove the 
limb, yet, from the small size of the joint and the accessible situation 
of all the parts with regard to surgical treatment, it is — except in cases 
of extreme complication and disorganization — comparatively safe in its 
results, and amputation is unnecessary. 

II. OBLIQUE FRACTURE OF EITHER CONDYLE. 

Before describing this fracture of the condyles, it may be proper to 
state, that modern anatomists have named the articulatory surfaces at 
the lower part of the humerus, the trochlea, and condyle, the former 
being the inner., the latter the outer articulatory surface, whilst the 
prominences beyond, or the eminences of attachment for the muscles, 
are named the epicondyle and the epitrochlea. The old nomenclature, 
however, is that followed by surgeons, namely, external and internal 
condyle, each condyle furnishing an articulatory surface and an emi- 
nence of attachment for muscles. 



142 FRACTURES OF THE HUMERUS. 

Fracture of either condyle may be either slight, as when the emi- 
nence of attachment only is broken off; or extensive, as when the arti- 
culatory surface is detached. 

FRACTURE OF THE INTERNAL CONDYLE. 

Symptoms. — When the fracture detaches but a small portion, the 
symptoms are a slight unnatural prominence, with crepitation and 
mobility, perceptible on grasping the part and bending the fore-arm 
backwards and forwards. 

"When the fracture is extensive, the forearm is bent, and the hand 
drawn a little inwards, and inclined to pronation ; when the forearm 
is extended, the broken condyle projects backwards, and with it the 
ulna, occasioning the appearance of dislocation of the ulna, which, how- 
ever, resumes its natural position when the forearm is bent. Additional 
symptoms are, mobility, crepitus, and pain on grasping the condyles 
and bending and extending the forearm ; and slight projection forward 
of the condyle in front of the ulna, if it be very violently extended. 

The nature of the displacement must be evident from what has been 
already stated. 

FRACTURE OF THE EXTERNAL CONDYLE. 

Symptoms. — When the fracture is slight, the symptoms are, — some 
degree of swelling about the external condyle, attended with pain ; cre- 
pitation and mobility, perceptible on grasping the condyles and per- 
forming pronation and supination of the hand. 

When the fracture is extensive, in addition to the above symptoms, 
the condyle is a little drawn backwards, and the radius with it ; the 
forearm is slightly bent ; and the hand is drawn outwards and inclined 
to supination. 

Treatment of slight and extensive fracture of each condyle. 

1. In both fractures of each condyle, preserve the forearm at a right 
angle with the arm. 

2. In extensive fracture of each condyle, apply a few turns of a roller 
round the joint, and then a wooden splint, the parts of which 
are at a right angle with each other, placing one part behind the 
humerus and the other below the forearm, and retain it by buckle 
bandages. 

3. In slight fractures of each condyle mould pasteboard splints to 
the joint, and retain them by a few turns of a roller or buckle 
bandages. 

4. In both fractures of the internal condyle pronate the hand and 
bend the fingers. 

5. In both fractures of the external condyle supinate the hand and 
extend the fingers. 

III. FRACTURE OF THE UNDER THIRD OF THE SHAFT OF THE HUMERUS. 

Symptoms. — Fracture in this situation is easily detected by inability 
on the part of the patient to raise the arm ; by unnatural mobility at a 
part, which in the sound state is inflexible ; by angular deformity on 
taking hold of the upper part of the humerus, and raising the arm ; 



FRACTURES OF THE HUMERUS. 143 

and by crepitation on grasping the bone above and below the fracture, 
and moving the parts on each other. 

Relation of the fractured portions. — In this situation there is little or 
no tendency to displacement, the parts above and below the fracture 
being equally embraced by the triceps behind and the brachialis anticus 
before. In fact, there is no tendency to displacement backwards, for- 
wards, or to either side, and seldom any in a longitudinal direction, unless 
the fracture be very oblique, when, as the resistance offered by the bone 
to the contraction of the muscles is removed, there is a tendency to 
shortening of the arm. 

Treatment. — This fracture is treated by applying two wooden splints, 
the one before, the other behind the humerus, and retaining them by 
means of buckle bandages, at the same time keeping the extremity in a 
sling, which should not be so short as to press up the elbow, but merely 
to support the weight of the limb. If the elbow should be pressed up 
by the sling being too short, and if the fracture should be oblique, the 
pressing of the fractured parts against each other may cause a shorten- 
ing of the arm. 

IV. FRACTURE OF THE MIDDLE OF THE HUMERUS. 

Symptoms, — The same as in the preceding injury. 

Nature of Displacement. — The displacement is rather more than in 
the fracture of the under third, the part below the fracture having a 
tendency to be drawn a little outwards. 

Treatment. — The same as in the preceding injury, except that the 
splints should be applied to the outer and inner sides of the arm. Some 
surgeons employ four splints in this fracture, one to the outside, one to 
the inside, one to the back, and one to the front of the arm. 

V. FRACTURE BELOW THE INSERTIONS OF THE THREE MUSCLES AND ABOVE 
THE INSERTION OF THE DELTOID. 

Symptoms. — In addition to the symptoms exhibited by the two pre- 
ceding injuries — mobility at a part naturally inflexible, inability to raise 
the extremity, crepitation, and angular deformity on raising the upper 
part of the humerus — this fracture has two symptoms peculiar to itself, 
namely, an unnatural swelling on the outside of the arm below, and 
another on the inner side above the fracture. These swellings are ex- 
plained by the nature of the displacement. 

Nature of Displacement. — -The muscles which cause displacement are 
four, namely, three inserted into the margins of the bicipital groove, the 
pectoralis major, latissimus clorsi, and teres major, which draw the upper 
part inwards, and the deltoid inserted below the fracture, which draws 
the lower part outwards, and, if the fracture be oblique, upwards : — in 
this case there will be slight shortening of the forearm in addition to 
the other symptoms. 

Treatment. — The first object of treatment is to obtain coaptation, 
which is easily 'effected by extension and counter-extension; then to 
preserve the extremity in the proper attitude, that is, with the arm by 
the side and the forearm at a right angle with the arm ; and to keep 
the parts at rest and in apposition. Desault's apparatus for preserving 



144 FRACTURES OF THE HUMERUS. 

the extremity at rest in the proper attitude, and maintaining apposition, 
consists of two long rollers — a wedge-shaped pad which will extend the 
whole length of the arm, — three splints, two of which should be the 
length of the humerus, the third shorter, and a sling, not too short, 
otherwise it will, especially if the fracture be oblique, produce displace- 
ment of the fractured portions by raising the elbow and forearm too 
high. 

Method of application. — Desault's directions are the following. Hav- 
ing damped one of .the rollers with a little lead lotion to prevent its 
slipping, apply two or three turns round the forearm, then along the 
whole of the arm as far as the axilla, lapping the edges well over in order 
to keep up equable pressure ; then take one or two turns of the roller 
under the axilla of the opposite side ; place the short splint on the front, 
one of the long splints on the back of the arm, and the other long one 
on the outer part ; taking care that the latter two extend along the 
w T hole length of the arm ; and secure the three splints in their respective 
places by bandaging the arm from the top downwards with the same 
roller, finishing on the forearm where it commenced. The wedge-shaped 
pad should then be placed between the arm and the thorax, having its 
base upwards in the axilla, that it may prevent the three muscles from 
drawing inwards the part above the fracture ; and then the second roller 
should be applied round the arm and chest to bandage them together, 
especial care be taken to apply it loosely above the fracture, that it may 
not press inwards the upper fragment ; but very firmly below, that it 
may prevent the lower portion from being drawn outwards. The fore- 
arm should then be supported by a sling, which, however, must not be 
so short as to press the elbow too much upwards. The above, which is 
Desault's treatment, answers very well, and is generally preferred. A 
simpler plan, which is also found to be successful, is, after obtaining 
coaptation and placing the extremity in the proper position, to apply 
four splints, one to the inner side, one to the outer, one to the front, 
and one to the back of the arm, and to retain them by means of buckle 
bandages ; then, after placing between the arm and chest a pyramidal 
pad with its base upwards, to bandage the arm and chest together, being 
careful, as in the other method, to make the bandage loose above and 
tight below the fracture ; and, lastly, to support the forearm by a sling, 
which must not be too short, for the reasons before stated. 

VI. FRACTURE ABOVE THE INSERTIONS OF THE THREE MUSCLES INTO THE 
BICIPITAL GROOVE, AND BELOW THE TUBEROSITIES; OR, AS IT IS OFTEN 
CALLED, FRACTURE OF THE SURGICAL NECK. 

Symptoms. — The symptoms differ from those of the last-described 
injury only in this, that the unnatural swelling on the outside of the 
arm is above the fracture, and that on the inner side below it. 

Nature of Displacement. — This is the very opposite of what is ob- 
served in the former injury ; the part above the fracture is drawn out- 
wards by the three muscles inserted into the greater tuberosity, namely, 
the supra spinatus, the infra spinatus, and the teres minor ; and the 
part below is drawn inwards by the three muscles inserted into the 



FRACTURES OF THE HUMERUS. 



145 



borders of the bicipital groove, namely, the pectoralis major, the latissi- 
mus dorsi, and the teres major. 

Treatment. — The treatment differs from that of the former fracture 
in only two respects : — the apex of the pyramidal pad should be up- 
wards ; and the roller which is put round the arm and chest to bandage 
them together, should be applied loosely below the fracture, that the 
lower fragment may not be drawn inwards, and very firmly above, to 
prevent the upper fragment from being drawn outwards. 



VII. FRACTURE OF THE ANATOMICAL NECK, OR BETWEEN THE BALL AND 

TUBEROSITIES. 



The possibility of fracture in this situation is no longer a matter of 
doubt. Bichat saw, in the possession of Larbaud, 
the humerus of a young man, seventeen years of 



Fig. 22. 



age, 



the ball of which was broken off from the 




rest of the bone. Delpech records an instance 
proved by dissection. Professor Samuel Cooper 
refers to the case of a boy shown to him with a 
fracture of the neck, and Sir Astley Cooper's 
work contains several interesting cases. I have 
in my museum an interesting specimen of this 
comparatively rare fracture. 

The injury is almost always caused by direct 
violence. It is most frequently met with in 
youth, sometimes in old age, but very rarely in 
the middle period of life. Sir Astley Cooper's 
work contains the description of a case in an old 
person, where the existence of the fracture was 
proved by dissection. 

Symptoms. — Acute pain is experienced, and 
sometimes at the moment of the accident a 
sound is heard as of something breaking. There is sudden inability 
to move the limb, which lies powerless by the side, though it 
yields in the freest manner to any motion communicated to it. When 
the limb is moved, crepitation is generally very perceptible, but 
every movement creates great pain. On examining the shoulder near 
the outer part of the coracoid process, a projection of bone is usually 
felt, which disappears on extending the arm, but returns when the 
extending force is removed ; and immediately below the acromion pro- 
cess it is observed that there is no vacuity, in consequence of the ball 
remaining in the glenoid cavity. This is a diagnostic symptom between 
fracture of the neck of the humerus and dislocation of the shoulder. 
There may be a flatness of the arm on the outer side farther down, 
occasioned by the drawing in of a part of the deltoid by the upper 
extremity of the portion of bone below the fracture. If there be not 
very great swelling, it may be possible to feel the ball motionless in 
rotating the arm. 



Fig. 22. United fracture of anatomical neck of Humerus. From a preparation in my 



10 



146 FRACTURES OF THE SCAPULA. 

Nature of Displacement. — The ball remains in the glenoid cavity, 
and the shaft is drawn forwards and upwards to the front and outer side 
of the coracoid process. 

Treatment.- — On this subject Sir Astley Cooper says, " The best mode 
of treating these accidents consists, in the young, in applying a splint 
on the fore and back part of the arm, binding it on by a roller, placing 
a pad in the axilla, and using a clavicular bandage, supporting the hand, 
but not the elbow, in a sling, since, if the elbow be raised, the broken 
end of the bone is pressed forwards. In old persons the injury is more 
severe, and the force producing it is violent ; it therefore becomes neces- 
sary to reduce inflammation, and to apply leeches and evaporating 
lotions, to observe perfect rest at first, and after some time the same 
treatment as to bandages may be pursued as in the young. In both the 
old and the young, passive motion is to be employed so soon as the 
union is effected, which in youth is in a month, but it requires from two 
months to twenty weeks in old age. In all fractures about the upper 
part of the arm and shoulder, it is judicious to support the vessels of 
the hand and forearm by a bandage. If this precaution be neglected, 
the pressure on the axillary and cephalic veins will be apt to produce 
engorgement of the more distant parts, for the removal of which it is 
sometimes necessary to take oif for a time all retentive apparatus, and 
to confine the patient to the recumbent posture." 

FRACTURE OF THE SCAPULA. 

The comparative frequency of fractures of the scapula is thus stated 
by Mr. Lonsdale. Out of one thousand nine hundred and one cases of 
fractures generally, eighteen were of the scapula, and of these eight 
were of the acromion process, eight of the body, and two of the cervix. 

Fractures of the scapula may be divided into five classes : — fractures 
of the acromion process — of the inferior angle — of the body — of the 
coracoid process — and of the cervix. 

The first two classes are of most frequent occurrence. The body of 
the bone from its depth, covered position, and mobility, is by no means 
very liable to fracture, and the coracoid process and cervix are very 
seldom broken; hence Boyer remarks, they generally require great 
violence to break them, and then the contusion of the soft parts is a 
worse injury than the fracture ; for example, he has seen the coracoid 
process broken by the blow of the pole of a carriage, and the patient 
lose his life by the violence inflicted on the soft parts about the shoulder. 
—(Mai. Chir. t. iii.) 

FRACTURE OF THE ACROMION: 

Symptoms.— -The patient feels as if the shoulder were falling down, 
complains of a great sense of weight, and has little power to raise the 
arm. On tracing the spine from its base to the acromion process, it is 
observed that the part between the fracture and the clavicle is depressed, 
from being drawn down by the weight of the extremity, and the con- 
traction of the deltoid muscle. The roundness of the shoulder is lost ; 
the ball of the humerus falls as far down into the axilla as the capsular 
ligament will permit ; and the measurement from the sternal end of the 



FRACTURES OF THE SCAPULA. 147 

clavicle to the extremity of the injured shoulder, compared with the 
sound side, will be found to be diminished. On placing one hand over 
the acromion, and pressing up and rotating the humerus with the other, 
crepitation will be perceptible. When the humerus is raised, the 
deformity of the shoulder disappears ; but it returns when the arm is 
allowed to fall down. 

Nature of Displacement. — The scapula and the remaining portion of 
the acromion are drawn upwards and a little backwards by the trapezius 
and levator scapulae ; while the fractured part is drawn downwards and 
a little forwards by the weight of the extremity and the deltoid muscle. 

Treatment. — The objects to be attained in this case are, — 

First, To raise up the broken fragment, and keep it in its proper 
position. 

This can best be done 1 by raising up the elbow, and keeping it raised 
by a short sling ; the ball of the humerus is thus pressed up, and made 
to act as a splint in keeping the fractured parts in apposition. 

Secondly, To relax the deltoid muscle. 

This is best effected by placing a cushion between the elbow and the 
side. 

Thirdly, To keep the arm at rest in rather a backward position. 

This is easily done by bandaging it to the chest with a roller. And, 

Fourthly, To exert some pressure over the acromion, by which close 
coaptation may be secured ; and this may be effected by a few turns of 
the roller by which the arm is bandaged to the chest. 

It is quite possible to treat this fracture in a satisfactory manner by 
means of a cushion and a single roller, the latter being applied so as to 
bandage the arm to the chest, to raise up the elbow, and also to exert 
pressure over the acromion. Mr. Liston proposes the same simple 
apparatus as he recommends in fracture of the clavicle, which shall be 
described in treating of the fractures of that bone. 

FRACTURE OF THE INFERIOR ANGLE. 

Symptoms. — In this injury the detached angle can for the most part 
be felt to be too far forwards ; but the most diagnostic mark is, that it 
remains stationary, if motion be communicated to the scapula ; or, if 
the angle be moved, the scapula is unaffected by that motion. 

Nature of Displacement. — The body of the scapula remains in its 
natural situation, and the inferior angle is drawn forward, — a displace- 
ment caused, if the fracture be very near the angle, by the fibres of the 
serratus magnus ; and if it be higher up, by the same fibres and the 
teres major and latissimus dorsi muscles. 

Treatment. — The angle is too small to be easily kept back, and coap- 
tation is attempted by bringing the scapula forwards and downwards, 
and by keeping it in that position. The arm is pressed downwards, for- 
wards, and inwards, and in that situation bandaged to the chest, while 
by means of the 'roller by which the arm is secured, and one compress 
behind the body of the scapula for pressing it forwards, and another 
before the angle for keeping it backwards, the parts are maintained in 
apposition and at rest. 



148 



FRACTURES OF THE SCAPULA. 



FRACTURE OF THE BODY OF THE SCAPULA. 



Fig. 23. 




The fractures in this situation may 
be either transverse or longitudinal ; 
the latter, which is the less frequent, 
can generally be distinguished by 
crepitus, to which will be added, in 
transverse fractures, an irregularity 
of the posterior costa of the bone. 

There is little tendency to displace- 
ment, because all the parts surround- 
ing the fracture are embraced by 
muscles, both on the outer and inner 
aspects of the bone ; and all that is 
necessary in the way of treatment is 
to keep the arm in a sling, and the 
scapula forward by a few turns of a 
roller round the chest. If the frac- 
ture be completely transverse, then 
the under parts will be drawn for- 
wards, and the same treatment will 
be required as for fracture of the 
angle. 



FRACTURE OF THE CORACOID PROCESS. 

The distinctive characters of this injury are, — pain, which is increased 
by stretching back the arm, or by any voluntary effort to raise it ; and 
mobility of the coracoid process when the scapula is rendered immovable. 
This unnatural mobility is very perceptible on fixing the scapula, and 
moving the arm backwards and forwards. When the arm hangs by the 
side, the apex of the coracoid process can be felt lower than on the sound 
side. The fracture is easily discoverable. 

Nature of Displacement. — The scapula remains in its natural position, 
but the coracoid process is drawn downwards by the coraco-brachialis, 
and biceps muscles, and downwards and inwards by the pectoralis minor. 

Treatment. — The great object is to relax the coraco-brachialis, biceps, 
and pectoralis minor muscle, so as not to keep up the displacement. For 
this purpose the forearm should be bent on the arm, and the arm placed 
across the chest, and the scapula pressed downwards and forwards ; the 
parts being maintained in that position by bandages. Gentle compres- 
sion by a pad placed below the coracoid process is also useful for keeping 
the fragment in a proper position. Another important part of treatment 
is to keep the patient for some time in bed, with the shoulders bent 
downwards and forwards by means of pillows. 

There seems to be no reasonable prospect of osseous reunion. The 
new connexion is formed by a ligamentous substance. 



Fig. 23. Union of fracture of body of Scapula. From a preparation in my museum. 



FRACTURES OF THE SCAPULA. 



149 



FRACTURE OF THE NECK OF THE SCAPULA. 

By this injury is not to be understood fracture of the anatomical neck 
of the scapula, which is situated beyond the glenoid cavity, and before 
the coracoid process, but fracture of what has been called the surgical 
neck ; that is the narrow part of the bone, into the formation of a part 
of which the semilunar notch enters, and which is behind the root of the 
coracoid process. 

In this fracture the glenoid cavity and the coracoid process are both 
broken off from the rest of the bone. 

This is, comparatively, a very rare injury ; so that some excellent 
authorities have doubted the possibility of its taking place as the result 
of direct violence ; but its occurrence has now been proved by dissection. 
I have seen three examples of this fracture. One was in a woman up- 
wards of forty-five years of age — another, in a man upwards of fifty — 
and a third, in a lad of sixteen. They were all caused by falls on the 
upper and back part of the shoulder. That in the case of the lad hap- 
pened in consequence of falling over a deep embankment. The symp- 
toms were exceedingly well marked, and all the patients became per- 
fectly well : but in the case of the female not until the lapse of four 
months. 

Symptoms. — The signs of this injury are — flattening and falling down 
of the shoulder ; an unnatural depression under the acromion, and an 
unnatural tumour in the axilla caused by the head of the humerus ; 
symptoms which can all be made to disappear, by pressing up the arm, 
but which return as soon as the support to the arm is removed. The 
same appearances are presented in dislocation downwards of the humerus ; 
but the fracture is easily distinguished by observing with what facility 
the arm can be raised, and the symp- 
toms be made to disappear, and how 
immediately they return when the arm 
is left to itself. Besides these pecu- 
liarities, which are not found in dislo- 
cation, there is another symptom which 
clearly indicates fracture, namely, crepi- 
tation. Sir Astley Cooper remarks, 
that the best method of discovering the 
crepitus is, for the surgeon's hand to 
be placed on the top of the shoulder, 
and the point of the fore-finger to be 
rested on the coracoid process ; the 
arm being then rotated, the crepitus is 
directly perceived, because the coracoid 
process being attached to the glenoid 
cavity, and being broken off with it, 
though it remains itself uninjured, the 
crepitus is communicated through the 
medium of that process. 

Nature of Displacement. — The body 
of the bone remains in its natural posi- 



Fig. 24. 




150 FRACTURE OF THE CLAVICLE. 

tion, and the broken fragments is drawn downwards and inwards by the 
weight of the extremity. 

Treatment. — In the treatment of this fracture, three things are to 
be done : first, the head of the humerus is to be kept outwards ; secondly, 
the glenoid cavity and the neck of the scapula are to be raised by 
elevating the humerus ; and thirdly, the parts are to be kept at rest. 
The appliances necessary for these purposes are, — a pad in the axilla 
for keeping out the head of the humerus ; a short sling for maintaining 
the arm in a raised position ; and a roller to preserve the parts at rest 
by bandaging the arm to the chest. 

In the adult, the time required for recovery from this accident is about 
three months. 

FRACTURE OF THE CLAVICLE. 

As the clavicle is unprotected by soft parts, unsupported in its middle, 
is of considerable length in comparison with its thickness, and from its 
position between the scapula and sternum, has to sustain any shock 
received on the shoulder, or on the glenoid cavity of the scapula — as 
when a person falls on the hand with the arm extended — it is very 
liable to fracture. According to Mr. Lonsdale, of all fractures that 
occur in the vicinity of the Middlesex Hospital, one-seventh are frac- 
tures of the clavicle. 

Causes. — This fracture may be occasioned by direct violence, as by 
a blow ; or by striking against a hard substance in a fall ; or by indirect 
violence, or counter-stroke, as by a fall on the point of the shoulder, 
when the clavicle has to sustain the force of the shock, or by a fall on 
the elbow or hand, when the extremity is extended. 

Situation of Fracture. — The fracture, if caused by directly concen- 
trated force, may be at any part of the bone to which the force is 
applied ; but it may be stated as a general rule, that fractures take 
place most frequently in the middle of the bone, and in the scapular 
more frequently than in the sternal extremity. On this subject Mr. T. 
Wilkinson, King's Lecturer on Comparative Anatomy and Physiology 
at Guy's Hospital, remarks : — "I have under my immediate observation 
twenty-two examples of broken clavicles repaired. Of these, fifteen have 
been divided close to the middle, or very slightly external to this point ; 
but two of the same have also been divided at about one inch from their 
outer extremities. Four other specimens have been broken transversely 
in the situations last named. The remaining three have been fractured 
about an inch from their sternal ends. One of the cases said to have 
been broken near the middle has had about three-fourths of an inch 
isolated by a double transverse fracture, which is also split longitudinally 
into two parts. The proportions stand thus : — 

Clavicles broken at the middle simply, . . . .12 

" " at the middle twice, ... 1 

" " at the middle and outer end, . . .2 

" " at the outer end only, ... 4 

" " at the inner end only, . . . .3" 

Thus it is very evident, that the strong cylindrical arch formed by 
the inner half of the collar-bone, is very little susceptible of fracture, 



FRACTURE OF THE CLAVICLE. 151 

although much exposed to direct blows. As a general rule, it may be 
stated that fractures take place in large proportion towards the outer 
end of this arch, and but rarely near its middle. With respect to the 
outer half, fracture is still uncommon, and almost confined to a trans- 
verse division about one inch from the outer point. 

For facilitating the description of fractures of the clavicle, it will be 
convenient to divide them into those on the scapular and those on the 
sternal side of the attachment of the coraco-clavicular ligaments to 
the outer tubercle of the bone. 

FRACTURE ON THE SCAPULAR SIDE OF THE CORACO-CLAVICULAR 
LIGAMENTS. 

Symptoms. — On very careful examination it will generally be found, 
that the part of the bone on the outer side of the fracture is drawn 
very slightly downwards. This symptom, never very perceptible in this 
fracture, can sometimes scarcely be discovered ; but it will be made 
more obvious by pulling down the arm, and on pressing the arm up- 
wards the fragment will be replaced, so as to be on a line with the rest 
of the clavicle. On placing one hand over the fracture, and with the 
other alternately elevating and depressing the shoulder, crepitus will be 
perceived. Sometimes the parts remain so nearly in their natural 
position, that the usual motions of the arm can still be performed. 

Nature of Displacement. — There is very little displacement, the part 
on the outer side of the fracture being retained in its position by its 
attachment to the acromion process by the acromio-clavicular ligaments, 
and the part on the inner side by the coraco-clavicular ligaments. This 
connexion of the parts on each side of the fracture with the processes 
of the scapula, prevents any further displacement than a very slight 
depression of the outer fragment, occasioned by the weight of the ex- 
tremity. 

Treatment. — If there be no displacement, all that is necessary in the 
way of treatment is to preserve the parts at rest by keeping the extre- 
mity supported by a sling, and the arm bandaged to the side. If there 
be displacement, the same treatment answers as for the fracture next to 
be described, excepting that the pad in the axilla should be very small, 
the fragment not having the same tendency, as in the next case, to fall 
towards the chest. 

FRACTURE ON THE STERNAL SIDE OF THE CORACO-CLAVICULAR 
LIGAMENTS. 

Symptoms. — The broken clavicle being no longer able to sustain the 
weight of the extremity, or to keep off the scapula from the chest, the 
arm falls down, drawing with it the part on the scapular side of the 
fracture, and thus occasions an unnatural depression, which, together 
with the prominence caused by the sternal end remaining in its natural 
situation, clearly points out the nature of the injury. The scapula 
being no longer kept back by the broken clavicle, the shoulder and arm 
fall inwards and forwards, rendering the distance between the sternal end 
of the clavicle and the apex of the shoulder, less on the affected than on the 
sound side, and the arm is drawn forward towards the breast. By press- 



152 FRACTURE OF THE CLAVICLE. 

ing the head of the humerus very forcibly upwards and outwards, the 
symptoms may be made to disappear, but they immediately return 
when the force is removed. The patient inclines the head and neck to 
the shoulder, and takes off the weight from the broken clavicle when 
standing, by supporting the elbow with the opposite hand ; and when 
sitting, by resting the elbow on the knee. He is unable to raise the 
hand to his head in consequence of the humerus no longer having a 
fixed point of support. There is swelling from extravasated blood over 
the bone, and crepitation may be perceived by raising the arm and 
carrying it backwards so as to bring the fractured surfaces in contact ; 
but attempts to discover this symptom occasion great pain. 

Nature of Displacement. — The part on the sternal side of the frac- 
ture, though it appears to be drawn upwards from the falling down of 
the remaining portion, is in its natural situation, being retained there 
by the power of the sterno-cleido-mastoideus muscle above, and of the 
costo-clavicular ligament, and pectoralis major muscle below. The 
scapular portion is displaced in three directions, namely, downwards, 
inwards, and forwards ; downwards, chiefly by the weight of the extre- 
mity, assisted perhaps by the contraction of the deltoid, — and inwards 
and forwards by the pectorales muscles, the broken clavicle being no 
longer able to keep the shoulder outwards and backwards. The scapu- 
lar part of the clavicle is thus drawn under the sternal portion, so that 
the one part rests upon the other. 

Treatment. — The parts are to be brought on a level w T ith each other, 
and the fractured ends into apposition, and to be preserved in this situa- 
tion. To effect this the outer portion of the bone must be raised up- 
wards, and also drawn outwards and backwards ; which may be done 
by pressing the humerus very forcibly upwards, and keeping it raised 
by a short sling ; and then placing a thick pad beneath the axilla, 
drawing the arm backwards, and bandaging the elbow firmly to the 
trunk. The pad acts as a fulcrum, the humerus as a lever, and the 
bandage as the power ; and thus the upper part of the humerus, and 
with it the scapula and the outer portion of the clavicle, are drawn 
outwards and backwards. 

In the treatment of this fracture many different kinds of appliances 
have been used. At one time it was the practice of many, when the 
shoulders had been drawn back, and were held fixed in that position, to 
place one end of a roller in the axilla of the injured arm, then to apply 
the roller obliquely across the back over the shoulder of the opposite 
side, and afterwards to wind it through the axilla of that side, and from 
that obliquely upwards over the shoulder of the affected side, and having 
made this figure-of-8 turn secure, to make several other turns succes- 
sively in the same manner. The shoulder having been thus bandaged back, 
the arm was placed in a sling. This is what was called the treatment 
by the figure-of-8 bandage. One objection to this treatment is, that 
the roller is apt to become roped, and to excoriate the edges of the 
axilla. To remedy this inconvenience, Brasdor suggested as an im- 
provement, the bandage which bears his name. It consists of a back- 
piece of stout leather softly cushioned, with two well-padded straps 
attached to the sides, and a belt running along its lower margin to sur- 



FRACTURE OF TEE CLAVICLE. 153 

round the waist, and to fix the bandage in its proper position. One of 
the straps is passed under each axilla, and returns over the shoulder to 
be buckled to the upper part of the back-piece : the back-piece is divided 
down the middle, and the two portions are connected by a lace, in order 
that it may fit persons of various sizes. 

The object of this appliance, is to draw back the shoulder; but this 
alone is insufficient. In treatment of fracture of the clavicle, three 
things are requisite : — to elevate the shoulder, to carry it out from the 
chest, and to throw it backwards so as to produce extension of the cla- 
vicle, and bring its overlapping ends into contact. With these views, 
and to effect these purposes, Desault constructed his bandage, which 
consists of two single-headed rollers, each nine yards in length, and a 
wedge-shaped pad for the axilla. The pad is placed in the axilla, and 
retained by two ribands attached to it, which are tied over the opposite 
shoulder ; the elbow is brought forward, lifted up, and pressed inwards 
against the chest, thus making the humerus act as a lever upon the pad 
in the axilla, for the purpose of extending the fractured clavicle. The 
arm being supported in this position, with the elbow bent at a right 
angle, one of the rollers is carried round the chest and upper arm, being 
drawn more tightly as it approaches the elbow ; a compress, dipped in 
camphorated spirits, is next laid upon the fractured bone, and the second 
roller, commencing in the opposite axilla, is carried across the chest, and 
over the compress and shoulder ; then, passing down behind the arm 
and under the elbow, it is again taken across the chest, and over the 
sound shoulder to the axilla, where it commenced ; and the same course 
is repeated till the roller terminates. The turns are secured by pins or 
stitches, and the hand is supported by a sling. 

Brunninghausen recommended for the treatment of this fracture, a 
leather strap, put on like the figure-of-8 bandage, with two pads fixed 
upon it, to prevent excoriation of the axilla. 

Of these four plans of treatment, the first two, together with Brun- 
ninghausen's, act on the same principle, namely, that of keeping back 
the shoulder ; but they leave unfulfilled the other indications, which are 
no less important. They are also liable to the following objection : — if 
any of the three different appliances be drawn tight to fix the shoulder, 
the shoulder will be drawn towards the chest, and, in consequence, the 
fractured parts will not be in apposition. On the other hand, the 
method of treatment recommended by Desault, is scientific and excellent; 
but as his manner of bandaging is rather complicated, and in the case of 
females very inconvenient, it has never been very generally adopted in 
this country. 

The following plan of treatment, recommended by my late friend, 
Mr. Liston, is simple, judicious, and unobjectionable. " When the patient 
is seen immediately after the accident, the bones are, without delay, and 
before inflammatory swelling has come on, to be placed in apposition 
and retained. No complicated apparatus is required. A pad, firm, 
though of soft material, and large enough to fill the armpit completely, 
is rolled in a shawl, and placed in the axilla ; it is retained by tying the 
shawl over the opposite shoulder, a soft pad being interposed between 
the knot and the skin to prevent excoriation, and is further secured by 



154 



FRACTURE OF THE CLAVICLE. 



tying the ends under the axilla of the uninjured extremity, which should 
also be protected by a small cushion. 

" A few turns of a roller, or a handkerchief, are placed round the arm 
and chest, so as to secure and fix the limb, and the retentive apparatus 
is completed. The shoulder is thus raised, and removed from its un- 
natural position, and the fractured extremities of the clavicle, previously 
placed in accurate contact, are prevented from being again displaced. 
The elbow and the forearm should be supported by a sling, otherwise 
the unsupported weight of the limb dragging on the shoulder will cause 
considerable pain, and subsequent displacement will be apt to occur. 
The apparatus should be looked to occasionally, adjusted and tightened ; 
and the cushions should be replaced by fresh ones, to prevent excoria- 
tion and uneasiness. The bone will be found to be quite smooth, to 
remain of its proper length, to unite generally within twenty days, and 
that without any unseemly exuberance of callus. No compress or splin- 
ters need be applied over the bone ; no evaporating lotions are necessary. 
If the patient be bruised in other parts, and become feverish, it may be 
requisite to abstract blood, and to exhibit antimonials, purgatives, &c. 
But all inflammation, arising from the fracture, subsides on the accom- 
plishment of reduction, adaptation, and retention of the portions. If 
the fracture be compound, the edges of the wound should be brought 
together, and retained, so as to favour immediate union." 

[The apparatus of Dr. Fox, of the Pennsylvania Hospital, is the one 
generally used in that Institution, and in this city. It is simple in its 
construction, easily applied, and fulfils all the indications. It consists 

of a collar, pad, and sling. The 
Fig. 25 - collar is made of muslin, and is 

merely a stuffed ring encircling the 
sound shoulder, and its use is to 
afford a firm point of resistance, to 
which the other parts of the appa- 
ratus may be attached. 

The pad is wedge-shaped, and 
should be sufficiently large at its 
upper extremity to act as a fulcrum 
when placed in the axilla, whilst the 
humerus is used as a lever. Broad 
tapes are attached to the two cor- 
ners of the thick end of the pad ; 
one tape is brought across the chest 
and tied to the collar, the other tape 
is brought across the back, and tied 
to the collar behind, and thus the 
pad is firmly secured in the axilla. 
The sling is made of strong linen or muslin, sufficiently large to con- 
tain the forearm and elbow. Cords or tapes are fastened to the sling 
near the elbow and wrist. When the sling has been applied, it is 
to be secured by bringing the tape from the humeral portion of the 
sling across the back, and tying it to the collar. The tapes from the 
carpal corners of the sling are to be carried up in front of the chest, 




FRACTURES OF THE THIGH-BONE. 



155 



and also fastened to the collar. By these means the shoulder can be 
drawn upwards, outwards, and backwards, and the fragments retained 
in coaptation. — Ed.] 



FRACTURES OF THE THIGH-BONE. 



FRACTURES OF THE NECK OF THE THIGH-BONE. 

Fractures of the neck of the femur may take place in any point of 
its extent ; and they often extend outwards through the trochanter 
major, but very seldom inwards, so as to traverse the articular surface. 
The articular surface presents a remarkable difference, as to its ten- 
dency to disease, and its liability to injury from fracture. It is very 
prone to disease ; it is scarcely ever the subject of fracture. 

Arrangement. — Fractures of the cervix femoris are divided into three 
classes : — 

1st. Intra-capsular transverse fracture, so named from its being 
within the capsular ligament, and nearly forming a right angle with 
the long axis of the neck of the femur. 

2d. Extra-capsular transverse fracture, when the fracture is without 
the capsular ligament, and the neck is broken off at its junction with 
the trochanter major. 

3d. Oblique fracture of the neck, extending through the trochanter 
major. This fracture may be partly within, and partly without the 
capsular ligament. 

intra-capsular transverse fracture. 

Symptoms. — I. Shortening of the extremity of the affected side. 

This symptom may be discovered by placing the patient straight on 
his back, and comparing accurately the two limbs, knees, and ankles ; 
or by comparing the measurement, between a 
fixed point of the pelvis and one below the sup- Fi g- 26 - 

posed fracture with the measurement between 
the corresponding point on the opposite side of 
the body. In the entire state of the bone, the 
muscles extending from the pelvis to the femur are 
kept somewhat on the stretch by the resistance 
which the neck and head of the bone offer to 
their contraction ; but when the neck is fractured, 
the resistance is diminished, and the femur is 
consequently drawn up by the contraction of the 
muscles. When the patient is in the recumbent 
posture, the shortening is caused entirely by the 
action of the muscles : but in the erect position 
not only is the part external to the fracture 
drawn up by the muscles, but also the part of 
the neck internal to the fracture is pressed down 
by the weight of the body. 

This symptom is usually less apparent immediately after the injury 




156 



FRACTURES OF THE THIGH-BONE. 



than at a subsequent period, some time being required for the complete 
contraction of the muscles. As shortening is a symptom of some of 
the dislocations of the hip-joint, it is of the greatest importance for the 
purpose of diagnosis to attend to all the distinguishing peculiarities of 
the shortening from fracture. In addition to the peculiarity already 
stated, namely, that the shortening is not so apparent immediately after 
the injury, until the muscles have had time to contract, it may be re- 
marked that for some time the injured limb may, by being drawn clown, 
be easily made of the same length as the other, but it returns to its 
former position as soon as the extending force is discontinued. After 
a very considerable period, however, the muscles become so permanently 

contracted, that they are capable of 
Fi g- 2 "- resisting a force which was pre- 

viously sufficient to bring down the 
limb. 

The degree of shortening varies 
much in different kinds of fracture. 
In intra-capsular fracture there is a 
difference of opinion on the subject 
among surgical authorities. Sir Ast- 
ley Cooper states, 1 " The leg be- 
comes from one to two inches shorter 
than the other, for the connexion 
of the trochanter major with the 
head of the bone by means of the 
cervix being destroyed by the frac- 
ture, the trochanter is drawn up by 
the muscles as high as the capsular 
ligament will permit, and consequently 
rests upon the edge of the acetabulum, 
and upon the ilium above it." The 
degree of shortening here specified is 
greater than has been found in the 
experience of Boyer, and some other 
continental authorities, or in that of 
Messrs. Listori, Stanley, Samuel 
Cooper, and R. W. Smith. Mr. Smith 
states as the result of his observation 
that the shortening in this fracture 
varies from a quarter of an inch to 
an inch, and in this opinion most 
surgical authorities now agree. Mr. 
Smith refers to fifteen examples of 
fracture of the neck of the femur in 
the Museum of Richmond Hospital, 
thirteen of which were taken from 
patients who died in the hospital, and 
in each case the degree of shortening was carefully observed. In one in- 
stance only did it exceed an inch, and in that it was an inch and a half; 

1 New edition of Sir Astley Cooper's Treatise on Dislocations and Fractures, by Mr. 
Bransby B. Cooper, p. 149, Am. edition. 







FRACTURES OF THE THIGH-BONE. 157 

but the accident had happened some years previous to the measurement, 
and the neck of the bone had been absorbed. In two instances I had the 
opportunity of measuring the degree of shortening, and of verifying by 
dissection that the fractures were entirely within the capsular ligament. 
The one case was that of a woman, seventy years of age, and the shorten- 
ing was three-quarters of an inch. Death took place two months after the 
accident, and on dissection the fracture was found to be within the cap- 
sular ligament, which did not appear to have been lacerated. The other 
case was that of a man, whose precise age could not be ascertained, but 
who appeared to be considerably above forty years : he met with this frac- 
ture, together with that of several ribs, and other serious injuries, by 
falling from the top of a house upon the pavement. The shortening 
equalled one inch. Death took place ten days after the accident ; and 
on dissection it was found that the fracture was entirely within the 
capsular ligament, which in this instance was rather extensively lace- 
rated, especially above. The extent of retraction seems to depend very 
much on the circumstance whether or not the capsular ligament over 
the neck of the bone be torn ; for although, as Boyer remarks, it yields 
a little without being torn, yet if it remains entire, or nearly so, 1 retrac- 
tion may be almost completely prevented. This was found to be the 
case by Smith, Stanley, and others, and Mr. Liston remarks with regard 
to the same point, " In fracture within the capsule, and where the fibrous 
envelope of the neck of the bone is not completely torn, there can be but 
slight displacement ; and by the most attentive comparison of the two 
limbs, abbreviation of the one which has sustained the injury may not 
be detected." 

Sabatier, Dupuytren, and others, have found in many cases that there 
was no shortening for many days after the injury, and that then it took 
place very suddenly on the patient making some exertion, or during 
some movement in the examination of the limb. This sudden shorten- 
ing at a period remote from the injury is accounted for by Dupuytren 
on the supposition that the fracture is within the capsular ligament, and 
by reason of some irregularity in the fractured surfaces the one fragment 
is wedged into the other, or the displacement of the one prevented by 
the position of the other, but that during some movement of the limb, 
the relations of the fragments become so altered as to admit of retraction. 
Mr. Smith and others agree with Dupuytren in viewing it as a sign of 
the fracture being within the capsular ligament, but they attribute it to 
the ligament suddenly giving way at the moment of the retraction. 

II. JEversion of the Foot and Knee is a frequent, but not an invariable 
symptom of this fracture. There is great difference of opinion as to 
the cause of this symptom. Sir Astley Cooper considered, and most 
British surgeons agree with him, that it is occasioned by the rotator 
muscles. Bichat and Boyer thought that it is produced by the weight 
of the foot. Dupuytren ascribes it to the direction of the fracture, and 
the relations of, the fractured portions to each other ; and Mr. Liston 
says, " The position would appear to depend upon chance in a great 
measure, and upon the way in which the limb has bent under the patient, 
or has been placed on his being taken up. The position may be altered 

1 Louis has asserted that the displacement may be considerable, but he has not sup- 
ported this assertion by facts or reasoning. 



158 FRACTURES OF THE THIGH-BONE. 

during the examination of the limb ; it may first be inverted, and after- 
wards, by the weight and inclination of the limb and foot, and the action 
of the powerful rotators outwards, the toes may become everted." In 
explanation of the more general outward direction of the toes, Sir Astley 
Cooper remarks, — " This state depends upon the numerous and strong 
external rotatory muscles of the hip-joint, which proceed from the pelvis 
to be inserted into the thigh-bone, and to which very feeble antagonists 
are provided ; thus, the obturators, the pyriformis, the gemini and quad- 
ratus, the pectinalis ' and triceps, all assist in rolling the thigh-bone 
outwards; whilst only a part of the glutseus medius and minimus, and 
the tensor vaginae femoris are the principal agents in rotation inwards. 
It has been denied that this eversion is caused by the muscles, and it 
has been attributed to the mere weight of the limb ; but any one may 
satisfy himself that it arises chiefly from the muscles, by feeling the 
resistance which is made to any attempt at rotation of the thigh inwards. 
This difficulty of rotation inwards is also in some measure attributable 
to the length of the cervix femoris, which remains attached to the tro- 
chanter major, because in proportion to its length which rests against 
the ilium, the trochanter is prevented from turning forwards." In ad- 
dition to the tensor vaginae femoris and anterior parts of glutasus medius 
and minimus, the two ischio-tibial muscles, namely, the semi-tendinosus 
and semi-membranosus muscles should be enumerated as rotators in- 
wards. When the foot is advanced, they prevent the heel from being so 
much turned inwards as to obstruct the other foot ; but since they are 
more relaxed than usual by the shortening of the extremity, they can 
in this fracture have no effect in counteracting the powerful rotators 
outwards. Eversion does not take place to its full extent for some 
hours, as the contraction of the muscles is gradual. 

Bichat and Boyer, as it has been already stated, attributed the ever- 
sion to the weight of the foot, and thought that if it were caused by- 
muscular contraction, there would be more difficulty in turning the foot 
inwards. Bichat also objected, that if the eversion were occasioned by 
the action of the rotators outwards, this position of the foot would be 
invariably met with, which is not the case ; an objection which applies 
as strongly to his own explanation as to that which he rejects ; and he 
further states, that in consequence of the fracture, the external rotator 
muscles, going from the pelvis to the part of the thigh-bone beyond the 
fracture, have, with the exception of the quadratus femoris, their ex- 
tremities approximated, and are, consequently in a state of relaxation. 
In answer to this it has been stated that the general influence of the 
muscles is to draw up the trochanter, and thus to operate against 
the relaxation of the rotators, and even to augment their influence. 

Baron Dupuytren suggests that the position of the foot may depend on 
the direction of the fracture, and the relative situation of the frag- 
ments : that if the outer fragment be in front of the inner, the foot will 
be turned outwards, but if the outer be behind the inner fragment, the 
foot will be inverted. 

Although eversion is the usual position of the foot in fracture of the 
neck of the thigh-bone, it is necessary to remember that inversion is 
occasionally found. The following case, recorded by Mr. Stanley, is a 
striking instance of this, while it also shows the importance of correct 



FRACTURES OF THE THIGH-BONE. 



159 



Fig. 28. 



diagnosis : — " A middle-aged man fell in the street, and his hip struck 
the curb-stone. The immediate consequences were, that the limb was 
inverted and shortened to the extent of an inch, and no crepitus could 
be discovered. It was presumed that a dislocation had occurred, and 
accordingly an extension of the limb was made, and so great was the 
constitutional irritation occasioned by the repeated trials to reduce the 
supposed dislocation, that the man died about five months from the 
time of the accident. In the dissection of the hip, a fracture was found, 
extending obliquely through the neck of the femur, but entirely within 
the capsule. A portion of fibrous 
and synovial membrane on the 
anterior side of the neck of the 
bone had escaped laceration." 
The surgical authorities of this 
country record many cases of 
inversion, in addition to the 
above-mentioned example given 
by Mr. Stanley. Sir Astley 
Cooper, at page 158 of his work 
on Dislocations, mentions the 
case of Mrs. Whateley, sixty 
years of age, in which the toes 
were turned inwards, and on 
dissection the fracture was found 
within the capsular ligament. 
Mr. Guthrie, in an interesting 
paper in the Med. Chir. Trans. 
vol. xiii., refers to a case of Mr. 
Langstaff's, in which there was 
inversion, and on dissection there 
was a diagonal fracture through 
the trochanter major. He also 
mentions a case in which the 
limb, having been in the first 
instance everted, suddenly 
turned inwards when the patient 
began to use it. Some French 
authorities refer to inversion in 
fractures of the neck of the 
femur as a more frequent symp- 
tom than it is admitted to be by 
surgeons of this country. Pare' 
and Petit describe the derange- 
ment inwards, as they call it, of 
the foot, as having taken place 
in all the cases of this kind 
which came under their notice. 
Desault concluded from his 




Fig. 28. Case of fracture of Cervix Femoris, accompanied with much shortening of 
the limb, but unattended with either inversion or eversion. From a patient in my wards 
in the Royal Infirmary. 



160 FRACTURES OF THE THIGH-BONE. 

experience that the cases of rotatory derangement inward were to those 
outward in the proportion of 1 : 4. 

As to the occasional occurrence of inversion, there is now no doubt, but 
much difference of opinion exists as to its cause. Some have supposed that 
the capsular ligament remaining entire in the front of the joint, and re- 
taining an attachment to the bone beyond the fracture, might cause 
inversion ; but although this condition might possibly prevent eversion, 
and even that is doubtful, it could have no effect in causing inversion. 
Others agree with Baron Dupuytren, who attributes the direction of the 
foot in every fracture of the neck to the relative positions of the frac- 
tured portions ; and if this explanation be not correct, the cause of 
inversion in fracture, entirely within the capsular ligament, remains 
still undiscovered. Mr. Guthrie has explained, in a most satisfactory 
manner, the cause of inversion in some fractures, without the capsular 
ligament. If the fracture be so situated, that the attachments of the 
rotators outwards inserted into the digital cavity, are connected with 
the fragment between the fracture and the joint, and the attachments 
of the anterior fibres of the glutseus medius and minimus, to the ante- 
rior part of the trochanter major, are connected with the bone beyond 
the fracture, then the anterior fibres of these muscles will produce rota- 
tion inwards. This explanation, however, though most satisfactory in 
certain fractures without the capsular ligament, will not apply to frac- 
tures entirely within it. 

III. Another distinguishing peculiarity of fracture, is the absence of 
a fixed condition of the limb. It cannot usually be moved by the volun- 
tary efforts of the patient, but it can be lengthened, or turned inwards 
or outwards by the surgeon, on the application of very slight force, but 
it returns to its former position as soon as the force is removed. This 
is a good diagnostic symptom, for distinguishing a fracture with the rare 
symptom of inversion from dislocation, in which the extremity is fixed, 
and cannot be restored to its former position, without very great force, 
and when restored, it remains in the proper position, and the natural 
mobility returns. 

IV. Crepitus is another symptom. If the patient be placed in the 
horizontal position, and the limb, if retracted, lengthened so as to bring 
the fragments to a level with each other, it may be readily discovered, 
by placing one hand over the trochanter major, and giving to the limb 
a quick rotatory motion with the other. 

V. The degree and kind of revolution performed by the trochanter 
under the hand, when the limb is rotated, is an evidence of the existence 
of fracture, and of its proximity to the trochanter. When the neck of 
the bone is entire, the trochanter during rotation describes a segment of 
a circle, the centre of which' is in the joint; but in fracture it seems to 
turn on its own axis, or to describe an arc of greater or less extent, ac- 
cording to the distance or proximity of the fracture to the trochanter. 

VI. The other symptoms are, pain, which is less in this than in the 
other fractures of the neck, and is not much felt, except when the limb 
is moved ; and some unnatural appearances near the injury, such as the 
trochanter being less prominent than usual, and too near the crista of 
the ilium ; and there being an unusual fulness of the hip caused by the 



FRACTURES OF THE THIGH-BONE. 



161 



bulging out of the muscles between the ilium and trochanter, and a 
swelling, more or less conspicuous, at the upper and fore-part of the 
thigh. The only injuries for which this fracture could be mistaken, are 
dislocation forwards of the hip-joint, when the fracture, as is usual, is 
attended with eversion (the diagnosis between them will be pointed out 
when the dislocation is described) ; and dislocation upwards or back- 
wards, when the fracture is attended with the rare symptom of inversion. 
In the dislocations the shortening is greater ; the inversion is much 
more than even in the rare instance of its being found in fracture ; the 
knee is brought forward ; there is immobility of the whole limb, and 
the absence of crepitus ; whereas in fracture with inversion the shortening 
and inversion are less ; the limb is so movable, that by a very slight 
force it may be rotated, or bent backwards and forwards, which, how- 
ever, causes great pain, and there is crepitus and the peculiarity of the 
revolution of the trochanter. 



EXTRA-CAPSULAR TRANSVERSE FRACTURE. 

Symptoms. — Shortening. According to Sir A^ley Cooper, this 
varies from half to three quarters of an inch ; but, according to Mr. 
Smith, with whom most surgeons agree, it is usually from one inch and 
a half, to two inches and a half. Smith, Boyer, Stanley, and Earle, have 
all found the shortening greater in this than in the former fracture, there 
being nothing to prevent the muscles from drawing up the outer frag- 
ment, while the inner fragment is pressed down by the weight of the 
body. 

Eversion of the foot. Inversion also sometimes, though rarely occurs, 
as has been stated under the same symptom in the last fracture. There 
is always, as some term it, rotatory derangement 
of the limb, and for the most part, outwards. Fig. 29. 

Crepitus is another symptom, which can gene- 
rally be elicited without difficulty, as in the 
former fracture. 

Mobility of the limb, which though immovable 
by the voluntary efforts of the patient, nearly to 
the same extent as in dislocation, can be bent, 
extended, lengthened, or rotated outwards and 
inwards by the surgeon by slight force, but it 
returns to its former position when the force is 
discontinued. 

Pain, to a greater extent than in intracapsu- 
lar fracture, even when the limb is at rest, and 
always exceedingly severe, when it is moved by 
the surgeon. The severity of suffering is much 
greater than in the former fracture, and there is 
sometimes, in consequence, considerable irritative 
fever. 

It may also be remarked, that the trochanter is less prominent than 
usual. If the hand be placed over it when the limb is rotated, it will 
seem to move on its own axis, instead of describing an arc ; it is too 
near the crista of the ilium. The hip is altered in form, as in the last- 

11 




162 



FRACTURES OF THE THIGH-BONE. 



mentioned fracture. There is swelling at the upper and fore-part of 
the thigh; and ecchymosis and tenderness to the touch are often ob- 
served. This fracture, though it may take place in old age, is often 
met with under fifty, and sometimes in early life, and is usually occa- 
sioned by much greater violence than is necessary to produce intracap- 
sular fracture. 



Fig. 30. 




OBLIQUE FRACTURE OF THE NECK, EXTENDING THROUGH THE TROCHANTER 

MAJOR. 

Symptoms. — If there be any shortening of the limb (which is not 
always the case), it is usually to a less extent than in the other fractures. 
The extent of surface of the fractured part, and 
the direction of the fracture, often prevent this 
kind of displacement. 

Crepitus is usually perceptible, and generally 
the foot is turned outwards, but seldom to the 
same extent as in the other fractures ; in some 
instances it is turned inwards, the rationale of 
which, as explained by Guthrie, is given in a for- 
mer page under the head of Symptoms of Intra- 
capsular Fracture. The foot is benumbed, the 
patient is unable to sit, and any attempt to do so 
causes great suffering, nor can he turn in bed 
without much pain ; great tenderness is felt on 
pressure, and ecchymosis may often be discerned. 
In some cases the upper part of the trochanter 
does not obey the motions of the limb, but remains 
at rest; sometimes it is drawn upwards, and a 
separation is perceptible between it and the rest 
of the bone ; and if the fracture be very oblique 
and below the attachments of the principal rotator muscles, the bone 
may be drawn up by the glutaeus maximus, and a considerable shorten- 
ing of the limb be thus occasioned. This last symptom, however, is 
more characteristic of oblique fracture of the trochanter major, not ex- 
tending, or very slightly extending, into the neck. 

This fracture is usually the result of very great violence applied to 
the trochanter. 

PERIOD OF LIFE AT WHICH FRACTURE OF THE NECK MOST FREQUENTLY OCCURS. 

The patients under Baron Dupuytren with fracture within the liga- 
ment, were almost all above fifty years of age ; and Sir Astley Cooper 
says, " I have now been thirty-nine years connected with St. Thomas's 
and Guy's Hospitals, and for« thirty years have enjoyed no inconsidera- 
ble share of the surgical practice of London. In the two hospitals there 
are one thousand and fifty patients, and I believe eight cases of fracture 
of the upper part of the thigh-bone occur in each year ; but in order to 
avoid exceeding the average number, I will consider them only as five 
per annum ; thirty-nine multiplied by five produce one hundred and 
ninety-five ; adding to these one case only in each year in my private 
practice of thirty years, they will collectively amount to two hundred 



FRACTURES OF THE THIGH-BONE. 163 

and twenty-five cases. Now in that time I have only known two cases 
of fracture of the neck of the thigh-bone within the capsular ligament 
occur under fifty years of age ; one was in a patient aged thirty-eight 
years, who had an aneurism of the iliac artery ; and the other was 
kindly shown to me by that excellent anatomist and surgeon, Mr. Her- 
bert Mayo." 

Mr. Stanley has recorded a case in a boy aged eighteen years ; and 
in the museum of Guy's Hospital there is a specimen of fracture of the 
neck, which, however, involves the trochanter, taken from a child nine 
years of age. Fracture within the capsule is almost exclusively con- 
fined to persons above fifty years of age ; it is very seldom met with in 
adults below that age, and is still more uncommon in children : women 
of advanced age are more liable to it than men. The causes of these 
differences will be explained below. The other two varieties of frac- 
ture of the neck may take place in advanced life ; but they occur under 
fifty years of age more commonly than intra-capsular fracture, and are 
usually the result of great violence, whereas a very slight accident is 
sufficient to occasion fracture within the capsular ligament. 

Causes. — The causes may be divided into exciting and predisposing 
causes. The exciting causes of the several fractures have been arranged 
by Dupuytren in the following order, according to their frequency : — 
1. Falls on the trochanter. 2. Direct violence, such as that of a gun- 
shot wound. 3. Falls on the foot or knee. 4. Muscular action, as 
recorded to have taken place once in tetanus. According to Desault's 
experience, in twenty-four cases out of thirty, the accident was occa- 
sioned by falls on the trochanter ; whereas Sir Astley Cooper found the 
most common cause to be a slip off the edge of the foot pavement. He 
remarks with reference to fracture within the capsule : " In London the 
accident most frequently occurs when persons walking on the edge of 
the elevated footpath, slip upon the carriage pavement ; though the 
descent be only a few inches, yet being sudden and unexpected, and the 
force acting perpendicularly with the advantage of a lever in the cervix, 
it produces a fracture in the neck of the thigh-bone ; and as a fall is 
the consequence, the fracture is imputed by ignorant persons to the fall 
and not to its true cause. Other trivial accidents may also produce 
this fracture. I was informed by a person, that being at her counter, 
and suddenly turning to a drawer behind her, some projection in the 
floor caught her foot and prevented its turning with the body, by which 
the neck of the thigh-bone became fractured. A fall on the trochanter 
major will also produce it ; but I have dwelt particularly on the slight 
cause by which it is occasioned, that the young surgeon may be upon 
his guard respecting it ; as he might otherwise believe that an injury of 
such importance could scarcely be the result of a slight accident, and 
that excessive violence is necessary to break the neck of the thigh-bone : 
but such an opinion is as liable to be injurious to his reputation as the 
error of confounding this accident with dislocation. Sir Astley Cooper 
found the other two varieties of fracture to result generally from a vio- 
lent blow, or a fall on the trochanter. In fracture within the capsule, 
when caused in the manner already described, the fall is often the con- 



164 FRACTURES OF THE THIGH-BONE. 

sequence of the accident ; in the others, the accident is generally the 
consequence of the fall. 

When a person falls on the great trochanter, the neck of the femur is 
acted on by that eminence, which has a point oVappui on the ground, 
and by the weight of the body, which acts immediately on the head of 
the femur. By this action and reaction a force is exerted on the neck 
of the femur, which tends to make it parallel with the rest of the bone. 
In falling on the feet, on the contrary, the tendency of the fracturing 
cause is to force the -neck of the femur to form a right angle with the 
bone, and if this force be exerted on the bone beyond its natural exten- 
sibility, a fracture must ensue. 

According to the two last-mentioned views of the mechanism of these 
fractures, they are not direct, that is, not produced by a cause acting 
immediately on the part, but the effect of a force communicated to that 
part by contre-coup, or transmitted reaction. If, however, the fracture 
be the result of a severe contusion or fall, and be through the trochanter 
or without the capsule, the fracture is so near to the part to which the 
violence is applied that its influence may be said to be direct. 

The different degrees of frequency with which these fractures occur 
at the different periods of life, and in the two sexes, may be explained 
by anatomical and other considerations. In the child, the trochanter is 
concealed under the prominence of the os innominatum ; the trochanter 
projects but slightly, and the axis of the neck approaches that of the 
shaft. These circumstances, together with the diminished breadth of 
the pelvis, the great flexibility of the neck, and the adipose and cellular 
tissues which are all protective, account for the extremely rare occur- 
rence of these fractures in childhood. In adults the pelvis is broader, 
the trochanter is more prominent, the neck is longer, and its inclination 
to the shaft is at a greater angle ; consequently there is more liability 
to fracture in mature age than in childhood, and there would be still 
more than there is, but for the great strength and solidity of the bone 
at that period. In advanced life the pelvis is still broad, the trochanter 
is prominent, and often but little protected, in consequence of the dimi- 
nished size of the muscles and the decrease of the adipose and cellular 
tissue ; and the neck of the thigh-bone, besides being nearly at a right 
angle with the shaft, is also rendered exceedingly brittle by the diminu- 
tion of cartilaginous matter and the increase of phosphate of lime ; 
also by a peculiar process of atrophy, which has been admirably described 
by Sir Astley Cooper. To these circumstances is ascribed the greater 
liability to fracture in old age. 

Dupuytren states, that the frequency of this accident bears a direct 
ratio to the prominence of the trochanter major, the length of the neck, 
and its angle with the shaft, and he ascribes the greater liability to it 
in women to the circumstance that the neck of the femur is longer and 
the trochanter more prominent, while the size and prominence of the 
muscles which would protect the bone, are often less in this sex than in 
the other. The very liability to fall in old age must also increase the 
frequency of fracture. The observations of Sir Astley Cooper, above 
referred to, are as follows. " The neck of the thigh-bone in persons of 
middle age has a close cancellated structure, and is covered by a shell of 



FRACTURES OF THE THIGH-BONE. 165 

considerable thickness ; but in old subjects the cancellated structure 
degenerates into a coarse network, loaded with adipose matter, and the 
shell which covers it becomes so thin that when a section is made 
through the middle of the head and cervix, it is found diaphanous. Of 
this I have several specimens. As the shell becomes thin, ossific matter 
is deposited on the upper side of the cervix, opposite the edge of the 
acetabulum, and often a similar portion at its lower part, and thus the 
strength of the bone is in some degree preserved. This state may be 
frequently seen in very old persons. When the absorption of the neck 
proceeds faster than the deposit on its surface, the bone breaks from 
the very slightest causes, and this deposit wears so much the appear- 
ance of a united fracture that it might easily be mistaken for it. 
Before the bone thus alters we sometimes meet with a remarkable but- 
tress shooting up from the shaft of the bone into its head (formed of 
strong cancelli), giving it additional support to that which it receives 
from the deposit of bone upon its external surface. 

" But another change is also produced, of which the following is the 
history. Old, bedridden, and fat persons, generally females, often used 
to be brought into our dissecting-room with some of their bones broken, 
and more frequently the thigh-bone than any other, in being removed 
from the grave. If the cervix femoris of such persons be examined, it 
will be found that the head of the bone is sunk down upon its shaft, 
and that the neck of the thigh-bone is shortened, so that its head is in 
contact with the shaft of the bone opposite to the trochanter minor ; and 
at the point at which the ligament is united with the neck of the bone 
the phosphate of lime is absorbed, and a ligamento-cartilaginous sub- 
stance occupies its place, either extending (as a plane) entirely through 
the neck of the bone, or partially, so that one section exhibits signs of 
it, and in another it is wanting. The bone in some cases is so soft and 
fragile, both in its trochanters and head, that it will scarcely bear the 
slightest handling ; and the motion of the thigh-bone in the acetabulum 
is almost entirely lost, so that the persons must have had but little use 
in their lower extremities. In examining the body of an old subject 
very much loaded with fat, in the dissecting-room of St. Thomas's Hos- 
pital, I found that the gentleman who had dissected one limb had cut 
through the capsular ligament of the hip-joint, and tried to remove the 
head of the thigh-bone from the acetabulum, but the neck of the bone 
broke on the employment of a very slight force, and, upon a farther 
trial to remove it, the bone crumbled under the fingers. As the other 
limb was not yet dissected, I requested Mr. South, one of our demonstra- 
tors, to remove with care the upper part of the other thigh-bone, but, 
although he used great caution in doing it, he could not remove the 
bone without fracturing the upper part of its shaft ; but he succeeded 
in removing the upper part of the bone, so that it might be preserved ; 
and of this I have given plates. We have here then a case in which 
the neck of the .bone was absorbed, so that the head was brought in 
contact with the trochanter ; in which, most decidedly, there had not 
been a fracture, although it had in some parts the appearance of one, 
and in which the disease occurred in each hip-joint. 

" Another case of the same kind was examined by Mr. South, which, 



166 FRACTURES OF THE THIGH-BONE. 

so far as it relates to the softened state of the upper part of the thigh- 
bone, was similar to the former ; the heads were spongy, the necks 
were shortened, so that there was scarcely any remaining ; each trochan- 
ter was light in weight and very large ; and there was little, if any, 
motion in either of the hip-joints, so that both limbs appeared, at first 
sight, as if dislocated on the pubes. But the best specimen of this state 
is the following, which I preserve with the most assiduous care, and 
value in the highest possible degree. I have had, for twenty years, in 
the collection of St.. Thomas's Hospital, the thigh-bone of an old person, 
in which the head of the bone had sunk towards its shaft. I have been 
in the habit of showing this bone twice a-year, as a specimen how bones 
sometimes become soft from age and disease, and from the absorption of 
their phosphate of lime ; and I have frequently cut with a penknife both 
its head and its condyles, to show the softened state. On sawing through 
its cervix, the cartilage, deprived of its phosphate of lime, had dried 
away in several parts ; and the appearance was such, that a person 
ignorant of the change would have declared it to be a fracture, only that 
in some sections the cartilage has taken different directions (as a thin 
plane between the head and neck), and in some, the bone was not yet 
entirely absorbed." 

MODE OF UNION. 

In two of the three kinds of fracture of the cervix femoris, namely, 
extra-capsular transverse fracture, and oblique fracture through the tro- 
chanter major, the reunion is, as in other parts of the body, by bone ; but 
this mode of union is extremely rare in intra-capsular fracture. It was 
at one time a question about which there was much difference of opinion, 
whether reunion by bone could ever take place in fracture entirely within 
the capsular ligament, and where the head of the bone is completely in- 
sulated, except at its attachment to the acetabulum by means of the 
round ligament. The French surgeons believed that it could, and 
affirmed that preparations in their museums in Paris demonstrated that 
mode of union. Several British surgeons were of the same opinion. 
M. Roux of Paris sent a specimen of what he believed to be reunion by 
bone, to Sir Astley Cooper ; but Sir Astley was not satisfied, because 
the traces of reunion in that preparation were such as to indicate a frac- 
ture where the internal fragment retained a connexion with the capsular 
ligament. Mr. Cross of Norwich, in the account of his visit to the 
French hospitals, states that he examined the preparations in the 
museums of Paris, which were believed to demonstrate union by bone, 
but that he did not consider them satisfactory. 

No one in this country has devoted more attention to the investiga- 
tion of this subject than Sir .Astley Cooper ; and to show how rare an 
occurrence union by bone is in fracture entirely within the ligament, he 
enumerates not fewer than forty-three specimens of this fracture in 
different collections in London, and states that during his practice of 
forty years he had seen but two or three cases which militated against 
the opinion that union by bone cannot take place, and only one in which 
a bony union had taken place, or which did not admit of motion of one 
bone upon the other. Sir Astley Cooper never denied the possibility 



FRACTURES OF THE THIGH-BONE. 167 

of bony union ; he states that it would be presumptuous to maintain 
that there could be no exception to the general rule ; but he has proved 
that such exceptions are rare. Several cases are recorded, in which 
bony union unquestionably took place ; and we may therefore conclude 
that it may occur in very favourable cases, and under good treatment. 
Of various instances on record, I shall only refer to three. 

Mr. Longstaff's museum contained an unquestionable specimen of 
ossific union. The preparation is now in the Museum of the Royal 
College of Surgeons of England, where I have examined it. The par- 
ticulars of the case are recorded in the " Medico-Chirurgical Transac- 
tions." The patient died about two years after the accident. The 
ossific union is perfect in the shell, and all round the circumference of 
the bone ; the centre of the fissure is united by a fibrous substance. 

Another instance of bony union occurred in the case of Dr. James, 
an English physician, who met with this fracture by a fall from his 
horse, while riding in the neighbourhood of Bordeaux. He recovered 
from the accident, but died seven months after it, of visceral disease ; 
and, on examination by Dr. Brulatour of Bordeaux, it was found that 
the fracture was entirely within the capsule, and that the union by bone 
was perfect. 

In the second edition of Mr. Liston's " Elements of Surgery," p. 717, 
there is a drawing of complete bony union, which, Mr. Liston says, he 
is enabled to produce by the kindness of Sir Astley Cooper. The 
possibility of bony union is thus clear- 
ly demonstrated, but still it cannot be Fi S- 31 - 
looked for except in very favourable 
cases, and what has been already de- 
scribed as the frequent condition of 
the neck of the thigh-bone in aged 
persons, must render it in many in- 
stances hopeless. In the majority of 
cases of intra-capsular fracture, no 
union takes place, and the broken 
surfaces become smooth and polished 
from being covered over by what has 
been called the ivory deposit, or they 
may become joined to each other, or 
to the inner surface of the capsular 

ligament by fibrous bands, the capsular ligament and surrounding tissues 
become very much thickened and strengthened, and thus the unnatural 
motion is limited. The neck of the femur disappears by interstitial ab- 
sorption, and the diminished head rests between the two trochanters. 
These conditions, or some combinations of them, are the appearances 
which present themselves where bony union has not taken place. 

CAUSES OF THE WANT OF UNION. 

1. One circumstance which prevents bony union of the fragments is 

Fig. 31. Intra-capsular transverse fracture of cervix femoris, followed by absorption 
of the neck, and conversion of part of capsular ligament into exceedingly thick bands. 
From a preparation in my museum. 




168 FRACTURES OF THE THIGH-BONE. 

the want of proper and constant apposition. This is only in accordance 
with what is observed in other parts of the body, when fractured bones 
cannot be kept in contact. Under such circumstances ossific union 
rarely takes place, as may be clearly seen from the various cases and 
experiments recorded in the last edition of Sir Astley Cooper's work on 
"Fractures and Dislocations," beginning at page 139. 

2. Various proofs may be adduced that a certain degree of pressure 
of the fractured parts against each other is favourable to union. In 
the present case that pressure cannot easily be maintained, and this is 
another circumstance which contributes to prevent union. 

3. The atrophy of the cervix femoris, already described, not only 
predisposes to fracture, but also diminishes in a very great degree the 
power of reparation. This, and the want of vigour belonging to old 
age, even if no other reason could be assigned, would be sufficient to 
account for the want of union. 

4. A fourth reason is the feeble circulation through the head and 
neck on the inner side of the fracture, for, there being no periosteum, 
its circulation and vitality are kept up entirely by the vessels of the 
round ligament ; nor can the separated portion of the bone receive nu- 
trition from any other source. 

5. Another reason which has been assigned is, the circumstance of 
the synovial fluid being poured into the injured cavity ; but the effect of 
this is doubtful. 

Treatment. — The first question is, — Are we justified in subjecting the 
patient to the long and hazardous confinement to his bed necessary for 
a chance of union ? The answer to this will depend on the degree of 
probability that union will take place. It will now be evident that the in- 
quiries into the changes which the neck of the bone undergoes in age, 
the circumstances under which reunion takes place, and the causes 
which prevent it, are of great practical importance. In intra-capsular 
transverse fracture in advanced life, when there is little if any chance 
of reunion, it would be injudicious to run the risk of ruining the general 
health by long confinement to one position, and incur the danger of 
ulceration and sloughing of the integuments of various parts from the 
weight of the body, and the application of apparatus for adapting and 
retaining the parts in apposition. Sir Astley Cooper remarks, " Baffled 
in our various attempts at curing these cases, and finding the life of the 
patient occasionally sacrificed under the trials made to unite them, I 
should, if I sustained this accident in my own person, direct that a 
pillow should be placed under the limb throughout its length, and that 
another should be rolled up under the knee, and that the limb should 
be thus extended until the inflammation and pain be subsided. I should 
then daily rise and sit in a high chair, in order to prevent a degree of 
flexion which would be painful, and, walking with crutches, bear gently 
on the foot at first, then gradually more and more, until the ligament 
became thickened, and the muscles increased in their power. A high- 
heeled boot should be next employed, by which the halt would be much 
diminished." 

In extra-capsular transverse, and in oblique fractures through the 
trochanter, and even in intra-capsular transverse fractures in very 
favourable subjects, the following treatment may be adopted. 



FRACTURES OF THE THIGH-BONE. 169 

The patient being placed on a hard mattrass, in an extended position, 
with the trunk, thigh, and leg in a straight line, a common bandage 
being applied from the toes to above the knee, to prevent oedema, and 
coaptation having been obtained by extending the extremity, and placing 
it in a proper position, with the toes not too much turned inwards or 
outwards, a wooden splint of sufficient strength and breadth, and long 
enough to extend from the last rib to three or four inches beyond the 
foot, with two holes at its upper, and two notches or retiring angles at 
its lower, extremity, should be well padded and applied to the outer side 
of the limb, care being taken to protect the ankle by a suitable adjust- 
ment of pads. The leg and foot should then be fixed to the splint by a 
roller, from the foot to above the knee ; and if the roller, after some 
turns of it have been applied to the ankle, be passed through the notches, 
it will fasten the foot to the extremity of the splint, and prevent it from 
moving. A broad bandage should be applied around the pelvis, and 

Fig. 32. 




carried down the thigh so as to include all the part above the former 
roller, and by the turns of this bandage, or by a very broad band, the 
splint should be fastened to the trunk, by which means the fractured 
parts will be kept in contact. A large handkerchief or shawl, with a 
little tow or hair wrapped up in it to prevent its galling the skin, should 
be applied with its centre in the perineum, and one end behind the hip 
and the other in front, and these ends passing through the openings in 
the upper part of the splint, should then be well secured. The pelvis 
acts as a fulcrum, and the perineal band as the power, by tightening 
which the splint and the lower part of the limb previously fixed to it can 
be kept down, the extension be preserved, and the extremity be kept of 
the proper length. Great care should be taken that the splint be well 
padded with cotton, wool, wadding, or tow, to prevent the painful effects 
of pressure ; the bandages should be reapplied occasionally during the 
treatment, and the perineal band frequently tightened. The apparatus 
will require to be continued for at least seven or eight weeks ; but this 
will vary in different cases, according to the time necessary for procuring 
union. As satisfactory cures are obtained by this method as by any 
that can be adopted, and it has the recommendation of being simple and 
the least annoying of any to the patient. It has been strongly advo- 
cated by Mr. Liston, Professor Samuel Cooper, Mr. Fergusson, and 
others. 

The indications of treatment to be fulfilled are, to preserve the extre- 
mity elongated, and at perfect rest, to prevent eversion, and to keep up 
pressure upon the trochanter. 

Some recommend a different plan of treatment, namely, to keep the 



170 FRACTURES OF THE THIGH-BONE. 

body slightly elevated, and the limb on a double-inclined plane. This 
treatment can be more conveniently practised by means of Amesbury's 
bed than by any other apparatus. The first and third indications above 
stated are fulfilled by the footpiece of Amesbury's bed ; the bed itself 
accomplishes the second ; and the fourth and last is effected by a ban- 
dage or belt around the trunk, and a splint extending between the pelvis 
and the knee. I have treated cases satisfactorily by each of the above 
plans ; but my decided impression is that the former is to be preferred. 
Dupuytren recommended the double-inclined plane, and kept the extre- 
mity elongated by means of two belts, one of which he passed along the 
perineum, and attached to the upper bed-post ; the other he fixed to the 
knee, and fastened to the lower bed-post. 

FRACTURES OF THE SHAFT OF THE FEMUR. 

Symptoms. — These are so conspicuous as at once to satisfy the sur- 
geon of the nature of the injury. Acute pain at the moment the injury 
takes place, — inability to sustain the superincumbent weight, — angular 
deformity in raising the limb, — sudden inability to move the limb by 
the voluntary action of its own muscles, — and preternatural motion of 
the lower part of the thigh-bone when otherwise acted on, — are inva- 
riable symptoms ; and the following, though not always, are generally 
present. 

There is shortening of the extremity, if the fracture be oblique, vary- 
ing in extent according to the obliquity. To ascertain the extent of 
shortening, or longitudinal displacement, as it is sometimes called, take 
the anterior superior spinous process of the ilium and some prominent 
point at the under extremity of the femur, or head of the tibia, and 
compare the measurement with that between the corresponding parts on 
the opposite side of the body. Shortening of the limb may be prevented 
by the bone being splintered, and the two fractured extremities being 
locked into each other. This symptom may not appear immediately, 
the contractions of the muscles by which it is produced being gradual. 
If the fracture be transverse, there may be no shortening, unless the 
violence which produced the injury was so great, or applied in such a 
manner, as to force the lower fragment from resting at any point against 
the upper. 

Crepitation may be generally elicited, more especially if the fracture 
be transverse, by performing rotatory motion. If the fracture be oblique, 
this symptom may not be perceptible, until the limb has been elongated. 
The presence of crepitus is an indubitable proof of the existence of frac- 
ture, although its absence cannot be taken as an indication of the con- 
trary ; for it will sometimes be altogether prevented by the interposition 
of muscular fibres between the fractured portions. 

Tumefaction to a considerable extent may be present, the foot is for 
the most part turned a little outwards, and the femur is most accessible 
to the fingers along its sides. 

Nature of Displacement. — If the fracture be oblique, and if it be not 
very near either of the extremities of the shaft, — in which case there are 
some modifications of the displacement which will afterwards be stated, — 



FRACTURES OF THE THIGH-BONE. 171 

the part above the fracture has generally two, and the part below four 
peculiarities of displacement. The upper fragment is drawn too far for- 
wards by the psoas magnus and iliacus internus muscles ; which, in their 
way from the iliac fossa and lumbar division of the spine to the trochanter 
minor into which they are inserted, describe an arc, the convexity of which 
is forward. There being no longer the usual resistance offered to the 
contraction of these muscles they draw forward the upper fragment. It 
is also generally drawn a little outwards by the gluteus maximus muscle. 
Of course the upper part of the bone can undergo no retraction. The 
part below the fracture is displaced in the four following directions : — 

1st. It is displaced backwards, chiefly perhaps by its own weight, and 
by being overlapped by the upper part. 

2d. It is drawn too near the mesial plane. The course of the ad- 
ductor longus, brevis, and magnus, is from within outwards, and thus 
these muscles draw, or as their very name imports, they adduct, the 
lower fragment too near the mesial plane. 

3d. It is rotated outwards, thus occasioning eversion of the extremity. 
Some attribute this eversion to the mere weight of tfie limb, but as many 
of the fibres of the adductor muscles have the planes of their insertion 
farther back than the planes of their origin, it is probable that they 
assist in producing rotation outwards, and they will have a greater ten- 
dency to do so on account of the falling back of the lower fragment, 
which makes the plane of their insertion farther back than usual from 
those of their origin. 

4th. It is drawn upwards, producing shortening of the extremity. 
This displacement is occasioned chiefly by the muscles which go between 
the pelvis and the leg, namely the biceps, semi-tendinosus, semi-mem- 
branosus, rectus, and gracilis, assisted, no doubt, by the muscles inserted 
into the fragment below the fracture. If, however, the fracture be 
transverse, it may happen, on account of the breadth of surface of the 
fracture, that some part of the lower fragment presses against some part 
of the upper, in which case there will be no shortening ; but if the frac- 
ture be oblique, the contraction of the muscles will not be prevented by 
the position of the fractured portions, and consequently, shortening will 
take place. 

According to Mr. C. Aston Key, the displacement in fracture of the 
femur is not to be attributed to the action of the muscles inserted into 
the upper fragment ; but chiefly to that of the muscles which go to the 
lower fragment. He supposes that the muscles surrounding the frac- 
ture and inserted into the lower fragment become the subject, first of 
effusion of blood, and subsequently of serous infiltration in consequence 
of slight inflammation, and that they are thereby irritated, swelled, and 
excited to contract ; and the lower fragment being movable is thus 
drawn up. The direction of the upper fragment, according to Mr. Key, 
will then depend upon the direction of the plane of the fracture. If the 
fracture go from above downwards, and from within outwards, the lower 
fragment by being drawn upwards, presses the upper fragment forwards 
and outwards. If the plane of the fracture be from before backwards, 
and from without inwards, the effect of drawing up the lower fragment 



172 FRACTURES OF THE THIGH-BONE. 

will be to displace the upper fragment forwards and inwards. Accord- 
ing, therefore, to this authority, the displacement of the upper fragment 
is not so much caused by the action of its own muscles, as by the lower 
fragment, and the direction in which the upper fragment is displaced, 
by the drawing up of the lower, depends on the direction of the plane 
of the fracture. If the fracture be situated at the upper extremity of 
the shaft, the psoas magnus and iliacus interims draw the upper frag- 
ment directly forwards, producing a tumour in the groin ; and if the 
fracture be transverse and immediately above the condyles, the lower 
fragment is drawn downwards and backwards by the gastrocnemius ex- 
ternus, plantaris, and popliteus, so that the lower extremity of the upper 
fragment appears as if it were the part displaced. 

Treatment. — After coaptation of the fractured portions, which should 
be obtained as speedily as possible, the object of treatment is to pre- 
serve the parts at rest and properly adjusted ; which can be done by 
attention to attitude and application of apparatus. 

Attitude. — Various attitudes have been recommended. Desault ad- 
vises that the patient be placed on his back on a hard unyielding mat- 
trass, with the trunk, thigh, and leg in a straight line with each other ; 
this attitude he employed partly with a view of giving ease to the pa- 
tient, but chiefly that the muscles might be equally relaxed ; and appa- 
ratus be easily applied for keeping the limb extended, and at rest. 

A second attitude, now however completely abandoned, is that recom- 
mended by Pott, in which the patient is placed on the affected side with 
the trunk slightly inclined forwards, and the leg moderately backwards. 

For a description of this method of treatment see Pott's Surgical 
Works, vol. i. p. 318. A most decided objection to it is that it does 
not admit of extension, so that shortening and deformity of the limb, 
and eversion of the foot, are extremely apt to result from it. It is also 
exceedingly irksome to the patient. 

A third attitude is that proposed by Sir Charles Bell, in which the 
patient is placed on his back with the trunk raised, the thigh slightly 
bent on the pelvis, and the leg bent on the thigh. 

Mechanism. — This is, likewise, very various. The splint of Desault 
and also that of Boyer are appliances which were successfully employed 
by these celebrated surgeons, and although very complicated and cum- 
bersome, and not now employed in this country, yet they were useful 
on the very same principle as the apparatus now in most general use, 
and no doubt led to its introduction. The apparatus to which I allude 
is, in fact, the mechanism of Desault simplified; it has been very strongly 
recommended by Mr. Liston, and is now generally approved, and adopt- 
ed in all fractures of the shaft, except those at its very extremities. 

This plan of treatment being the same as that recommended for frac- 
ture of the neck of the femur, with the single exception that in addition to 
what is there used, a short wooden splint should be applied to the inside 
of the thigh, it is unnecessary again to describe it. It is of all methods 
the easiest to the patient ; it prevents eversions, shortening and defor- 
mity ; and the mechanism is so applied that the pelvis, thigh, leg, and 
foot constitute one rigid body, which may be moved entire, but the va- 
rious parts of which being immovable inter se, preserve the same mutual 



FRACTURES OF THE THIGH-BONE. 173 

relation. Some surgeons object to the treatment above described, if 
the fracture be at the upper extremity of the shaft and immediately 
below the trochanter minor, on the ground that — 1st. The psoas mag- 
nus and iliacus internus muscles having no antagonists, and being put 
on the stretch by the straight position, will draw the upper part too far 
forward ; and 2d. The perineal band, if made very tight, — and if it 
be not made tight it cannot answer the purpose for which it is employed, 
— will tend to assist the two muscles in increasing this displacement of 
the upper fragment. In consequence of these objections to the straight 
position, they advise that the patient be placed in the attitude recom- 
mended by Sir Charles Bell for the treatment of fractures of the shaft, 
but with this peculiarity, that the trunk should be so much raised as to 
make the patient sit erect for the purpose of relaxing the psoas magnus 
and iliacus internus muscles ; and that four wooden splints be applied, 
one to the front, another to the back, and one to each side of the limb. 
If the fracture be so nearly transverse that the upper fragment by 
pressing against the lower, may prevent its retraction, this treatment 
may answer; but if the fracture be at all oblique,' I would recommend 
the former plan,. which I have employed, even in this fracture, with the 
most satisfactory result. This fracture can be very conveniently and 
satisfactorily treated in the bent attitude, referred to above, by means 
of Amesbury's admirable apparatus or fracture-bed, for fractures at the 
upper part of the femur, along with four wooden splints, firmly applied 
to the front, back, and two sides of the thigh. This apparatus renders 
it unnecessary to move the patient's body for any purpose, and it has 
also the great advantage of making it practicable and easy to keep up 
extension, and thereby to prevent shortening of the limb. 

In transverse fracture, immediately above the condyles, or in the 
under third, the preferable attitude is to have the leg slightly bent, to 
relax the gastrocnemius externus, plantaris, and popliteus muscles, which 
draw backwards the lower fragment. The most elegant apparatus for 
the treatment of fracture in this situation, is M'Intyre's splint, which 
consists of a sandal, and leg and thigh-pieces ; the latter two forming a 
double inclined plane with each other. The thigh-piece is double, the 
one portion sliding on the other, and can be lengthened or shortened, 
and firmly fixed by means of a screw. By lengthening the thigh-piece, 
which can be done without removing it from the patient's body, exten- 
sion of the thigh can be kept up. The leg and thigh should be included 
in a roller along with the splint ; three short wooden splints should also 
be applied to the lower part of the thigh, namely, one in front and one 
on each side, and the roller should be carried up to the upper part of 
the shaft. By the above means the fractured portions will be kept in 
apposition and at rest : the whole of the extremity may be moved along 
with the splint, but the fractured portions will be preserved in contact, 
and their proper relations to each other effectually maintained. In 
oblique fracture . in the under third, notwithstanding the action of the 
muscles above referred to, I prefer the straight position, as that in which 
extension can be most effectually kept up, and shortening and deformity 
consequently prevented. 

[In this country fractures of the thigh are generally treated by an 



174 FRACTURES OF THE THIGH-BONE. 

apparatus which retains the limb in an extended position. The princi- 
ple of Desault's splint is the basis of numerous inventions, but the modi- 
fication of it by Dr. Physick is perhaps the most preferred. 

The pieces which compose Desault's apparatus, are, 1st. Common 
junk-cloth, accommodated to the size of the limb and the splints ; 2dly. 
A bandage for the body, and one passing under the thigh, to secure the 
first on the side opposite to the fracture ; 3dly. Three stiff splints, an inch 
and a half wide, the external one of which being very strong, must be 
long enough to extend from the spine of the ilium to the distance of four 
inches below the sole of the foot. This splint is hollowed out or notched 
at its lower end, and has a mortice in it a little higher up. The 
upper splint occupies the space included between the fold of the groin 
and the upper part of the knee ; and the internal one, which reaches 
from the upper and internal fold of the thigh, to the sole of 
Fi g- 33 - the foot ; 4thly. Three bolsters, an external, an internal, and 
an upper one, consisting of small bags of chaff; 5thly. A ban- 
dage of strips, accommodated, as to number, to the circum- 
stances of the case, separate from one another, each three 
inches broad, and long enough to go twice round the limb, 
arranged from below upwards, and overlapping each other, 
about one-third of their breadth ; 6thly. One long and two cir- 
cular compresses, intended to be applied immediately on the 
limb, next to the skin ; 7thly. Two strong rollers, intended for 
extension and counter-extension, at least an ell and a half long ; 
8thly. One long and thick compress, and a sufficient number of 
bits of tape. 1 

In this apparatus the line of the counter-extension is very 
oblique, owing to the perineal band being attached to the upper 
end of the splint, and the obliquity has a tendency to produce 
deformity, by inclining the upper fragment outward. 

Dr. Physick elongated the upper end of the splint so as it 
should reach to the axilla, and thus the line of the counter-ex- 
tending band was rendered very nearly parallel to the axis of the 
body ; and at the suggestion of Dr. Hutchinson, a small notched 
block is attached to the inner surface of the lower extremity of 
the splint. The extending bands passing over this notch neces- 
sarily act in a line parallel with the splint. In other respects 
Physick's apparatus is the same as that of Desault, although 
the third or anterior splint will not be found necessary in many 
cases. In applying this apparatus great care is requisite to 
render it effectual, and at the same time as comfortable as pos- 
sible. Much will depend upon the accuracy of the adaptation 
of the bran-bags, and upon the character of the material used 
for the extending and counter-extending bands. The great 
ground of complaint which has been urged against this dressing 
has arisen from a liability of excoriation at the perineum, and 
at the ankle. The perineal band should be made of soft yet 
firm muslin, and padded or stuffed in that part which presses 
against the perineum. The skin should be carefully examined 

' Caldwell's Translation of Bichat's edition of Desault's Surgery. 



FRACTURES OF THE THIGH-BONE. 175 

every day or so, and bathed with soap liniment. The extending band 
applied at the ankle may consist of a handkerchief or a gaiter to which 
strong tapes have been fastened, and benefit will result from changing 
the means of extension and counter-extension. 

Hagedorns apparatus is the least liable to objection on the ground of 
excoriation, there being no perineal band, and the counter-extension 
being made at the acetabulum of the sound side. Prof. Gibson, of the 
University of Pennsylvania, has modified this splint, and this apparatus 
is well known in this country. Dr. Gibson thus describes the original 
apparatus, and his improvement: 

" This method consists in extending the patient's limbs upon a mat- 
trass, and confining both feet, by gaiters or a handkerchief, to a foot- 
board, which is firmly secured upon the ends of two splints passed through 
mortices near its edges. These splints extend from the arm-pit, where they 
are padded like the head of a crutch, along each side of the body, thigh, 
and leg, beyond the foot, and, being well stuffed on their inner surfaces, 
to prevent irritation, are confined by six or eight broad tapes or ban- 
dages passed around the limbs, pelvis, chest, &c. 

" The principle upon which extension and counter-extension are 
effected by this contrivance will instantly be understood. The sound 
limb being extended serves as a splint to the broken one. Counter- 
Fig. 34. 




extension then is made upon the acetabulum of the sound side, and ex- 
tension upon the ankle of the injured limb, which, so long as the two 
feet are kept on the same level, cannot be shortened, provided rotation 
of the pelvis be prevented. This purpose is answered by extending the 
splints to the arm-pits, and not with a view, as might be supposed, of 
producing counter-extension at these points. Finding that the patient, 
in the original machine of Hagedorn (which consists of a single splint 
merely, and a foot-board, independently of leather straps, &c), could 
incline the pelvis towards the affected side, and thereby shorten the 
limb by causing the superior fragment to descend and overlap the infe- 
rior, the additional splint was added, and has been found to answer 
completely the end designed." (Gibson's Surgery, Vol. I.) 

If both thighs are fractured, the best plan of treatment is that recom- 
mended by Dr. Gibson. It consists in securing the feet to the upper 
extremity of a single inclined plane, by means of gaiters attached to a 
foot-board. The extension is made by the weight of the body. — Ed.] 

OBLIQUE FRACTURE OF EITHER CONDYLE. 

Symptoms. — This injury may be recognised by the crepitus which is 
felt on taking a firm hold of the condyles of the femur, and producing 



176 



FRACTURES OF THE THIGH-BONE. 



flexion and extension of the knee-joint. The mobility of the condyle is 
caused by the alternate contraction and relaxation of the gastrocnemius. 
When the leg is very much bent, a fissure may sometimes be detected. 
From the extension of the fracture into the joint, it is sometimes fol- 
lowed by inflammation of the knee-joint, and by that means has been 
known to give rise to serious consequences. 

[When both condyles are fractured, the symptoms are usually still 
more distinct. There is usually great mobility 
of the parts, and crepitation would be very dis- 
tinct. Upon flexing the knee, its breadth is 
greatly increased by the separation of the con- 
dyles, and the patella sinks deeply in the space 
between them. It is possible, however, that 
a fracture of both condyles may occur, and yet 
the most striking symptoms be wanting. 

A case of this kind has been reported by the 
editor in the July No. of the American Jour- 
nal of Medical Sciences, 1849. The injury 
was produced by jumping from the third story 
window of the Almshouse Hospital. There 
was neither crepitation, mobility, nor twisting 
of the limb. Passive flexion and extension of 
the leg was readily effected. There was no 
increased breadth at the knee-joint. The de- 
formity resembled a partial dislocation of the 
knee backwards. The leg was thrown back- 
ward, and the patella was very prominent. 

The patient recovered rapidly without a bad symptom, and about 
a year after died of typhus fever. The specimen, as can be seen from 
the wood-cut, shows but slight shortening and no increase of breadth at 
the articular extremity. The fragments were probably impacted, the 
structure being cellular, and the force of the counter-stroke in a fall 
from such a height being very great. — Ed.] 

Nature of Displacement. — The vasti muscles passing around the con- 
dyles, to be inserted into the patella, prevent great displacement. The 
fragment, however, has a tendency to be slightly drawn backwards by 
the gastrocnemius externus, and if the fracture be of the inner condyle, 
besides being slightly drawn backwards, it is also drawn a little upwards 
by the adductor magnus. 

Treatment. — The same treatment is pursued, whether there be frac- 
ture of the external, or internal condyle. The extended position is by 
all preferred, because the head of the tibia, acting as a splint, resists 
displacement. Pasteboard or gutta-percha splints, moistened in warm 
water, should be applied by means of a roller. In these injuries, inflam- 
mation within the cavity of the joint is much to be dreaded ; the use of 
pressure, therefore, by the above mechanism must be deferred until all 
inflammation has subsided. The rule to be observed is to keep the pro- 
per attitude from the commencement, but not to apply the mechanism 
until all danger of inflammation is past. 

[In fractures of either or both condyles it may be necessary to make 




FRACTURES OF PATELLA. 177 

extension and counter-extension, which can readily be effected by Phy- 
sick's modification of Desault's Splint. At the end of four or five 
weeks, passive motion should be commenced, to prevent stiffness of the 
joint. — Ed.] 

FRACTURES OF THE PATELLA. 

Fractures of the patella are either tranverse or longitudinal ; the for- 
mer are more frequent than the latter, the exciting causes being more 
numerous. Fractures of this bone may be either simple or compound ; 
but the compound fracture is fortunately of comparatively rare occur- 
rence. 

Fig. 36. Fig. 37. 





Transverse fracture. — This injury may be produced by direct violence, 
such as a fall or a blow, or by violent contraction of the four strong 
extensor muscles of the leg attached to the patella. Persons have been 
frequently known to meet with this fracture from the last-mentioned 
cause, while ascending a stair ; and the reason of this may be easily 
understood. The ordinary action of the rectus femoris and triceps exten- 
sor cruris is to bring the leg forward ; this they do by having their 
fixed points of attachment above, and they then extend the leg by 
drawing up the patella, which, through the medium of the ligamentum 
patellae, brings the leg forward. In ascending a flight of stairs the 
action of the muscles is exactly the reverse. When the leg is raised on 
the step to be ascended, the patella is made the fixed point of the attach- 
ment of the muscles, and in the half-bent position in which the leg is 
placed, the patella rests only by a small part of its posterior surface on 
the femur, its two extremities, and especially its apex, being unsus- 
tained. The four muscles, by their contraction, then raise up the femur, 
so as to be in a line with the leg, and while they do so, it is evident that 
the patella has to sustain the whole force of muscular action, together 
with the weight of the body. The apex of the bone has a tendency to 
be drawn downwards, and the upper part backwards, by the extensor 
muscles, so that while the middle part rests on the femur, and has to 
sustain the whole superincumbent weight and muscular action, if these 
be too much for the strength of the bone, it snaps, and the muscles 
having thus lost their under-fixed attachments, can no longer support 
the body, which consequently falls backwards. It is a popular mistake 
that the fall is the cause, whereas it is in fact the consequence, of the 
accident. This explains the reason why this accident frequently hap- 
pens to an individual ascending a flight of stairs with a burden on his 
back. This fracture has also been known to take place during an attack 
of convulsions, while the patient was stretched on his back ; and a case 

12 



178 



FRACTURES OF PATELLA, 



is on record in which it was produced bj placing the body of an indi- 
vidual in the position necessary for performing the operation of litho- 
tomy, and the straining of the muscles during the operation. 

Symptoms. — The fracture may be easily known by the two projec- 
tions formed by the fragments, and the unnatural depression between 
them, into which the fingers may be pressed down towards the femur, 
as far as the integuments will permit. The extent of the depression 
will depend on whether the ligamentous expansion covering the anterior 
surface of the patella be lacerated or not. The two fragments are 
easily movable, but any lateral movement of them is attended with 
pain. On bending the leg on the thigh, the space between the frag- 
ments is increased ; it is diminished in bending the thigh and extending 
the limb. The patient has not the power of extending the leg, nor of 
supporting the weight of the body on that leg, as the knee bends for- 
wards when the weight is placed upon it, from the loss of action in the 
extensor muscles. The manner in which the patient attempts to bring 
his leg forwards is also diagnostic ; he leans the body forward, and then 
swings forward the whole of the extremity by calling into action the 
muscles which bend the thigh upon the pelvis. The nature of the vio- 
lence, and the tumefaction which quickly follows from the extravasation 
of blood and secretion of synovia, are indicative of the character of the 
injury. 

Nature of Displacement. — The lower fragment remains in its natural 
position, and follows, together with the ligamentum patellae, the motions 
of the leg ; the upper fragment is drawn upwards by the four extensor 
muscles. The distance of the fragments from each other is increased 
by the bent position of the leg ; but it varies, according as the tendinous 
expansion from the muscles over the bone is more or less lacerated. If 
the aponeurosis escape with very little laceration, the separation of the 
fragments may be limited to a very small extent ; whereas, if it be com- 
pletely lacerated, they may be removed some inches from each other. 

Fig. 38. 




Sir Astley Cooper says the upper portion may be drawn up five 
inches, and others have referred to a specimen in the museum of St. 
Thomas's Hospital, in which the two fragments are connected by a 
broad structure fully five inches in length. 

Mode of Union. — Transverse fractures of the patella are very rarely 
united by bone, but in almost all cases by a ligamentous substance. It 



FRACTURES OF PATELLA. 179 

was long supposed that there was something peculiar about the structure 
of the patella which was unfavourable to the fresh formation of bone. 
Baron Larrey was the first who questioned the existence of this sup- 
posed peculiarity : he ascribed the rarity of bony union to the difficulty 
of keeping the fragments in immediate apposition ; and the correctness 
of his view, both as to the possibility of union by bone, and the cause of 
its rare occurrence, is now completely proved. 

That after fracture of the patella the union may take place by bone, 
can no longer be denied. In longitudinal fracture of the patella, it is 
even acknowledged to be the usual mode of union, — so frequently does 
it occur. In transverse fracture, though it is rarely met with, yet its 
possibility is incontestably proved. Sir Astley Cooper says : — " In a 
patient of my kind friend, M. Copart, of Paris, I once saw a case which 
appeared to me to be united by bone ; and Mr. Fielding, of Hull, has 
published a similar case." Sir Charles Bell, in his work " On Injuries 
of the Spine and Thigh-bone," says, p. 57: — " This very week a woman 
goes out of the Middlesex Hospital with a fractured patella united by 
bone, and you can feel the ridge of union. Admitting that we may be 
deceived in this, there can be no deception in the preparation, which I 
place in your hands ; you have the patella shattered and reunited by 
bone, and you perceive the fragments are united with perfect regu- 
larity." At p. 58, he says : — " I have besides, eight specimens of frac- 
tured patella reunited by ligament, and two by bone. The ninth speci- 
men decides the matter. You see that the fracture has not only been 
across, but that there has been a rent longitudinally." M. Lallement 
records an unequivocal specimen of union by bone in transverse fracture. 
It was proved by dissection of the part, after the death of the patient, 
from another affection. Mr. Wilson has found in dissection, specimens 
of union by bone in transverse fracture, and the collection of Dr. William 
Hunter is said to contain a well-marked example. On the possibility 
of bone being formed in fracture of the patella, there is now no differ- 
ence of opinion ; and that the cause of its extreme rarity in transverse 
fracture is the want of correct apposition, appears evident from the 
following considerations : — 

1. Bony union is very common in longitudinal, and very rare in trans- 
verse fracture ; and it seems difficult to assign any explanation of the 
difference, except the comparative facility in the one case, and the ex- 
treme difficulty in the other, of preserving the parts in apposition. 

2. If in longitudinal fracture the soft parts be so lacerated that it is 
difficult to preserve the fragments in apposition, then ligamentous union 
is the usual result. This seems to show clearly that the obstacle to 
bony union is the want of apposition. 

3. In the case recorded by Sir Astley Cooper of Mr. Marryatt, who 
was thrown from his gig as he was passing along the Strand, there was 
transverse fracture of the patella, and the lower fragment was also 
broken perpendicularly, so that the bone was divided into three pieces. 
The transverse fracture united by ligament, but the perpendicular by 
bone. 

4. In several instances Sir Astley Cooper divided the patella trans- 
versely in rabbits, by drawing the integuments to one side, and then 



180 FRACTURES OF PATELLA. 

placing a knife upon the bone, and striking the knife lightly with a 
mallet. He states, that in no instance in which he performed the ex- 
periment, either in the rabbit or in the dog, did he ever succeed in ob- 
taining bony union. He performed the experiment of dividing the bone 
longitudinally both in the rabbit and in the dog ; and when the precau- 
tion was taken not to divide the tendinous fibres above, nor the ligament 
below, so that the fragments were preserved in close apposition, bony 
union was readily obtained ; whereas, if these precautions were not 
attended to, the union- was ligamentous. 

5. Mr. George Gulliver has, in the " Edinburgh Medical and Surgical 
Journal," related a series of experiments on transverse division of the 
patella, in which he took care to divide the bone without destroying or in- 
terfering with the fibrous expansion in front of it ; and, except in one in- 
stance, in an old dog, where the union was ligamentous, the division 
was followed by perfect ossific union. The fibrous expansion, being un- 
injured, kept the parts in apposition. 

6. I had a case in which there was a crucial fracture of the patella 
in consequence of a contusion from the explosion of a stone in a quarry. 
The lateral fragments united by bone, the superior and inferior by 
ligament. 

The medium of union is almost uniformly ligamentous : and since the 
limb is as useful as when the union takes place by bone, and less liable 
to disruption, bony union being for a long time very susceptible of frac- 
ture, it is perhaps the most desirable result. 

Treatment. — The principal indications in treatment are to relax the 
four extensor muscles, to subdue inflammation of the joint, if it should 
occur, and to keep the fractured surfaces as close as possible together 
by means of mechanism. Attention to the first indication is essential 
to the fulfilment of the third. It is of the greatest importance carefully 
to attend to the period at which it is proper to commence the use of 
means for the attainment of these three objects : for the first, means 
should be taken as soon as the surgeon has an opportunity of seeing the 
injury ; for the second, as soon as symptoms of inflammation appear ; 
and for the third, not on any account at first, nor for several days, lest 
inflammation should come on, which would be aggravated by the pres- 
sure ; or, if inflammation has already occurred, not until it has subsided. 
For the purpose of relaxing the muscles, the trunk should be raised to 
the sitting posture to relax the rectus, the thigh should be bent on the 
pelvis, and the leg extended on a line with the thigh, having the heel 
elevated a little, so as to be higher than the knee, but not much raised, 
lest the position should be painfully constrained. In this attitude the 
parts of the skeleton, to which the extensor muscles are attached, are 
approximated. 

For subduing inflammatory symptoms of the joint, leeches, evaporat- 
ing lotions, and purgatives should be employed; and if the symptoms 
be violent, venesection, antimonials, and low diet, to an extent propor- 
tioned to the age and constitution of the patient. While the above re- 
medies must never be withheld when necessary, they ought always to be 
used as sparingly as possible, otherwise the energy of the reparative 
powers will be diminished. For preserving the fragments as closely in 



FRACTURES OF PATELLA. 181 

apposition as is practicable, various kinds of mechanism are employed, 
together with the attitude described above. For my own part, I prefer 
the simple means recommended by Mr. Liston, which I have used in this 
fracture with as favourable a result as could be reasonably wished. They 
consist of a simple roller applied from the foot to a little below the knee, 
to prevent swelling of the leg and foot from infiltration, and a straight 
wooden splint, hollow at its two extremities and well padded, extending 
along the back of the limb from a little below the tuberosity of the 
ischium to a little below the middle of the leg, and retained by a roller, 
not tightly applied. The fragment of bone connected with the rectus 
and triceps muscles should be pressed towards the fragment attached to 
the ligamentum patellae, before the under part of the thigh is included 
in the roller. Sir Astley Cooper recommends, as the best mechanism 
for this injury, a broad leather strap, buckled round the thigh just above 
the knee, from which a long strap descends, passes under the sole of the 
foot, and is brought up to a buckle on the opposite side of the thigh 
belt. The leg is enveloped in a roller, and the limb kept extended by 
a long splint behind the knee. Mr. Amesbury devised an apparatus for 
transverse fractures of the patella, which has been called the uniting 
bandage, and consists of two pieces of leather softly padded on the 
inner surface, and long enough to pass half way round the limb ; these 
are buckled firmly above and below the patella, by straps passing behind 
the limb. Two short straps, attached to the lower margin of the upper 
belt, are brought down one on either side of the patella, and buckled to 
the upper margin of the lower belt, tightly enough to approximate the 
opposite edges of the pads, and at the same time the two portions of the 
patella. A long strap is then carried down the outside of the leg from 
the upper pad, under the sole of the foot, and up the inside of the leg 
to meet a buckle on the inside of the same pad. A long splint is then 
applied to the back of the limb. The plan commonly adopted to bring 
the fragments towards each other is, to apply a circular bandage both 
above and below the fractured patella, drawing it together by tapes 
placed between the bandage and the limb. The tapes are tied over the 
rollers, and the upper fragment is thus kept down. It has been very 
justly objected to this common method of treatment, — and the objec- 
tion applies equally to Mr. Amesbury's, and to some others, which it is 
unnecessary here to describe, that all belts and bandages tightly applied 
above and below the fragments must press the extensors attached to the 
upper fragment towards the femur, and the ligamentum patellae back- 
wards, so as to sink towards the joint, and thus the upper and lower ex- 
tremities of the patella are pressed backwards, and the fractured sur- 
faces, instead of being in the same plane, are raised forwards, so as to 
form an angle with each other. As the under fragment has no tendency 
to displacement, no advantage whatever can result from pressure below 
it ; but it must be drawn downwards by pressing back the ligamentum 
patellae, besides having its broken surface inclined forwards instead of 
upwards. Mr. Lonsdale has contrived a very ingenious, but rather com- 
plicated apparatus, for preserving the fragments in apposition without 
circular constriction of the limb. A description of it will be found in 
his excellent work on Fractures. It is of the greatest consequence to 



182 FRACTURES OF PATELLA. 

have the medium of union as short as possible ; for if it be of great 
length, there will be proportionate retraction of the muscles, and conse- 
quently diminution of their power, and the patient, after his recovery, 
will not be able to walk quickly without a halt : — hence the importance 

of preserving the parts as nearly as possible in apposition. 

«■ 

LONGITUDINAL OR PERPENDICULAR FRACTURE. 

This injury is caused by direct, violence, and may be easily detected 
by careful manipulation. Progression is difficult and painful, but not 
impossible, and reunion by bone is readily effected. 

Treatment. — The joint is to be kept extended and at rest, the usual 
precautions to be taken against the occurrence of synovitis, and the 
ordinary methods to be adopted if it should occur. After all risk of 
synovitis is over, a slight lateral pressure is to be kept up, which can 
be conveniently done by pasteboard splints and a roller, or more ele- 
gantly by a pad on each side of the patella, and a laced knee-cap. As 
a precautionary measure, a straight splint should be applied behind the 
joint. 

COMPOUND OPEN, OR EXPOSED FRACTURE OF THE PATELLA. 

This is a very serious injury, and always gives rise to the greatest 
anxiety in the mind of the surgeon, not merely on account of its being 
open, which is in itself an unfavourable circumstance, but because the 
patella being a part of the knee-joint, that large articulation is laid open, 
and the danger is from the synovitis and its consequences, and the great 
constitutional irritation, which are apt to result. A wound extending 
into a joint is at all times a serious injury ; and when, as in open frac- 
ture of the patella, the joint is not only exposed, but the accident is 
complicated with injuries of the bone and soft tissues, which must give 
rise to inflammation, the accident is of a very dangerous character. 
Such injuries often prove fatal in a very short time, and when this hap- 
pens, it is usually in consequence of violent irritative fever caused by 
inflammation of the joint. The inflammation of the joint may prevent 
any opportunity of performing amputation, which should, on no account, 
be attempted, except after the patient has recovered from the collapse 
caused by the injury before the inflammation has commenced ; or after 
the active inflammation and constitutional irritation have subsided. 

At one time the regular practice was to amputate in all cases of com- 
pound fracture of the patella, the limb being sacrificed to save the life ; 
but now many limbs are saved w T hich formerly would have been removed. 
The circumstances which justify amputation are, — an irritable or debili- 
tated constitution, and more especially, if debilitated in consequence of 
bad habits, extensive laceration, or severe contusion, or the probability 
of the occurrence of sloughing of the soft parts. On the other hand, if 
the patient be of a healthy constitution, and not irritable ; if the wound 
be small, and sloughing not likely to take place, an attempt should be 
made to save the limb. For this purpose it should be laid at rest in the 
position proper for fracture of the patella, the edges of the wound should 
be brought together as speedily as possible, and every means taken to 
prevent violent inflammation, and to secure adhesion. When inflamma- 



FRACTURES OF THE BONES OF THE LEG. 183 

tion occurs, it must be combated by the vigorous employment of the 
ordinary antiphlogistic remedies, namely, venesection, purgatives, anti- 
monials, and low diet, together with the local use of leeches, and either 
cold or warm applications as may be found most grateful to the feelings 
of the patient. In all cases in which debilitating remedies are required 
by the character of the injury or disease, the judicious practitioner will 
always be careful not to employ them to a greater extent than seems 
absolutely necessary ; but in the treatment of inflammation supervening 
on fracture of the patella, it is especially necessary for the surgeon to 
remember, that while it is indispensable to use these remedies to an 
extent proportioned to the urgency of the symptoms and the age and 
constitution of the patient, care must at the same time be taken that 
the strength of the patient be not unnecessarily brought down, other- 
wise the power and energy of the reparative process will be diminished. 

Some patients recover with an anchylosed joint, and others, even after 
a severe injury, with the perfect use of the limb. 

Sir Astley Cooper has recorded five cases which were successfully 
treated. In one of these the recovery was with an anchylosed knee, 
and in the other four with the perfect use of the joint. One of the 
cases, a very fortunate one, occurred in the practice of Mr. Ward, of 
Nottingham : — although the opening into the joint was large, yet, as the 
patient was young and of good constitution, and as the tibia and femur, 
and their cartilages, were uninjured, and the soft parts around the 
wound were not lacerated nor contused, so that there was little proba- 
bility that extensive sloughing would take place, Mr. Ward resolved on 
endeavouring to save the limb, and the patient recovered with the per- 
fect use of the joint, Mr. Ward having afterwards seen him dancing 
quadrilles at a ball in Nottingham. There is a case recorded by Pro- 
fessor Samuel Cooper, which he saw in St. Bartholomew's Hospital, 
under Mr. Vincent, where the bone was much fractured and the wound 
extensive ; yet, after the formation of abscesses and the separation of 
several fragments, the patient recovered with a stiff joint. When I was 
an apprentice to my friend Dr. Ewing, I had the dressing of a very for- 
tunate case under his care, where, in consequence of the explosion of a 
stone in a quarry, the patella was broken into several pieces, and the 
joint extensively opened ; but as the person had an uncommonly good 
constitution, amputation was not performed, and after long confinement 
and the discharge of a considerable number of small fragments, he 
recovered with the perfect use of the joint. 

FRACTURES OF THE BONES OF THE LEG. 

These fractures are very common, as will appear from the following 
statistics. Dr. George W. Norris, one of the surgeons of the Pennsyl- 
vania Hospital, states that during the ten years from 1830 to 1839 
inclusive, there were treated in that Hospital nine hundred and forty- 
six fractures, of. which two hundred and ninety-three were of the leg. 
Dr. Wilkinson King states that of two hundred and twenty urgent cases 
of fractures admitted into Guy's Hospital in one year, sixty-six were of 
the leg; and according to Mr. Lonsdale, of one thousand one hundred 
and one fractures which indiscriminately presented themselves at the 



184 



FRACTURES OF THE BONES OF THE LEG. 



Middlesex Hospital, two hundred and eighty-nine were of the leg. 
They are the most common of all fractures, except those of the forearm, 
which according to Mr. Lonsdale and most authorities are somewhat 
more frequent. There is not entire agreement among surgeons as to 
the comparative frequency of the different fractures of the leg. Accord- 
ing to Baron Boyer they occur in the following order of frequency : — 

1. Fractures of both bones. 

2. Fractures of the tibia alone. 

3. Fractures of the fibula alone. 

This order of frequency, given by Boyer, seems to accord with the 
experience of Professor S. Cooper ; but Mr. Lonsdale found that of two 
hundred and eighty-nine fractures of the leg, one hundred and ninety- 
seven were of both bones, fifty-one of the fibula alone, and forty-one of 
the tibia alone. According to this statement, therefore, the following 
is the order in which the three classes of fractures of the leg most fre- 
quently occur : — 

1. Fractures of both bones. 

2. Fractures of the fibula alone. 

3. Fractures of the tibia alone. 

Fractures of the fibula seem to have occurred more frequently than 
usual in the experience of Dupuytren, who expresses his belief that 
they are more common than is generally stated, and that fractures of the 
lower third of the fibula form a third of all fractures of the leg. 



Fig. 




FRACTURES OF BOTH BONES. 

Causes. — These, which form more than half of all 
the fractures of the leg, are produced in various 
ways : — sometimes by a heavy body striking or falling 
upon or passing over the leg, in which case the frac- 
turing cause acting simultaneously on both bones, it is 
generally found that they are both broken at the same 
height ; or, by the body falling while the foot is fixed, 
or by the foot and under part of the leg becoming fixed, 
while the body is in rapid motion. Another cause of 
fracture of both bones is a fall or leap from a great 
height, the person alighting with the extremity ex- 
tended, and the body erect. The tibia, having to sus- 
tain the whole shock, first gives way, and almost always 
obliquely, and the fibula then receiving the force 
next becomes fractured. In these circumstances the 
fractures are not necessarily at corresponding parts 
of each bone ; for the force being applied to the 
ends of the bones, each gives way at its weakest 
part, the tibia frequently about the commencement 
of its under third, and the fibula within a short dis- 
tance of its upper extremity. 

Symptoms. — The symptoms which denote afracture 
of both bones are, — some change in the direction and 
shape of the limb, pain, inability to walk or sustain 



Fig. 39. From a preparation in my museum. 



FRACTURES OF THE BONES OF THE LEG. 185 

the weight of the body, mobility of the fractured pieces, irregularity 
perceptible on drawing the fingers along the anterior angle and inner 
surface of the tibia, crepitus on rotating the foot, and angular deformity 
on raising up the leg. If the fracture be oblique, the heel may be drawn 
upwards, and angular deformity may be perceptible in front ; the cause 
of which will be explained, when the position of the broken fragments is 
described. The manner in which the accident occurred will afford pre- 
sumptive evidence as to the nature of the injury ; but the above are 
characteristic symptoms. 

Nature of Displacement. — The displacement may be longitudinal, 
angular, or rotatory. The longitudinal displacement producing short- 
ening of the leg, is extremely rare in transverse fracture ; indeed, it can 
scarcely take place, inasmuch as the drawing up of the under fragments 
is prevented by the upper portions of the bone ; but if the fracture be 
very oblique, the under fragments may be drawn upwards by the mus- 
cles of the back of the leg, and thus slight shortening may take place. 
Angular displacement may be produced by the action of the extensor 
quadriceps muscle, by the action of the muscles on the back of the leg, 
or by the weight of the foot ; and in each case the salient angle will be 
in front. When the bones are fractured near the upper ends — a com- 
paratively rare occurrence, which can only take place as the result of 
direct violence, the upper fragment of the tibia is drawn forwards, there 
being no antagonist to the quadriceps, which is inserted immediately 
above the fracture. If the knee be bent, the quadriceps muscle will be put 
more on the stretch, and thus the upper fragment will be still more drawn 
forwards ; hence arises the great importance, in the treatment of this 
fracture, of keeping the leg extended. The above is the opinion gene- 
rally entertained regarding the cause of the displacement forwards of 
the upper fragment in this fracture, but it is objected to by Mr. C. 
Aston Key, who remarks, " It is not easy to understand why muscles 
situated far above the fracture, and sustaining no injury, should be dis- 
posed to act on the offensive, while those muscles that act in the oppo- 
site direction should be wholly passive on the occasion. It is still more 
difficult to comprehend, why the extensor quadriceps, lying upon the 
femur, should be disposed to such inconvenient action as that of per- 
versely drawing the upper portion of a broken tibia forwards ; the site 
of the fracture having no apparent connexion with the muscles to which 
the displacement is attributed." He supposes that the muscles sur- 
rounding the fracture, becoming distended by infiltration, are thereby 
put upon the stretch and irritated to contract, and that the lower frag- 
ment obeying that contraction is drawn upwards, and thus pushes the 
upper fragment forwards. The angular deformity may be caused, as 
has been stated, by the contraction of the muscles on the back of the 
leg, or by the weight of the foot, and in either case the projection or sa- 
lient angle is forward. Under such circumstances, the upper or the lower 
portion of the bone will project farthest, according to the direction of 
the plane of the fracture. If the plane of the fracture be from above 
downwards, and from before backwards, the projecting point will be the 
upper extremity of the lower fragment ; if the plane of the fracture be 
from above downwards, and from behind forwards, the lower fragment 



186 FRACTURES OF THE BONES OF THE LEG. 

will be drawn upwards by the powerful muscles of the calf, and will 
push forwards the lower extremity of the upper fragment, which in that 
instance forms the projecting point. Oblique fractures are very difficult 
to be managed, and the integuments are very apt to be torn by the pro- 
jecting points of the fragments. Rotatory displacement, called by some 
authors derangement in the circumference, arises from the inclination of 
the foot inwards or outwards, but most commonly in the latter direc- 
tion. 

To avoid repetition, the treatment of all fractures of the leg will be 
described under one head, after the peculiarities of the other two classes 
of these fractures have been explained. 

FRACTURES OF THE TIBIA. 

Causes. — This bone may be fractured by direct violence applied to 
itself, or by a fall on the foot. The tibia is fractured by a fall on the 
foot in the same way as the radius by a fall on the hand, and the injury 
in each instance is most likely to take place if the extremity be extended. 
As the radius receives on its lower part the whole of the shock from the 
hand, and on its upper part of the whole momentum of the body from 
the humerus, in the same way the lower part of the tibia receives from 
the foot the whole shock, and the upper part receives from the thigh- 
bone the whole momentum ; and as in each instance a single bone sus- 
tains the whole shock, it is easy to understand how the radius in one 
case, and the tibia in the other, may be fractured without a correspond- 
ing injury of the ulna or the fibula. In the lower third it may also be 
fractured by indirect violence, or by what is called by the French, contre- 
coup. 

Symptoms. — Since the fibula, by acting as a splint, prevents shorten- 
ing, or any particular deformity or alteration in the appearance of the 
limb, and the extent of the fractured surfaces tends also to prevent 
shortening and displacement, and since the difficulty of moving the frac- 
tured portions on each other renders crepitation less distinct than when 
both bones are fractured, and the patient has sometimes been known to 
be capable of supporting his body on the injured limb, diagnosis is more 
difficult in this than in the former fracture. The manner in which the 
injury was produced, and the pain for some time constant, continuing 
much longer than that from mere contusion, and increased on moving 
the limb, are presumptive signs. If the parts be minutely examined, 
some inequality will be perceived on moving the finger along the ante- 
rior angle or inner surface of the tibia ; and on taking hold of the ends 
of the bone and pushing them in opposite directions, some unnatural 
mobility, and generally slight crepitation also, will be perceptible. 

Nature of Displacement.— If the fracture be near the upper end of 
the bone, the upper fragment will, for the reason before given, be drawn 
forwards, especially if the knee be bent ; but if the foot be kept in a 
proper position, it is evident, from what has been already said in de- 
scribing the symptoms, that there will be little tendency to displace- 
ment of the fractured portions. 

The treatment will be afterwards described. 



FRACTURES OF THE BONES OF THE LEG. 187 



FRACTURES OF THE FIBULA. 

Causes. — Fracture of the fibula in its two upper thirds, while the 
tibia remains uninjured, can only be the result of direct violence, and 
the situation of the fracture will be the part to which the violence has 
been applied. The deep situation of the bone, the manner in which it 
is covered by the peronei muscles, and its elasticity, allowing it to yield 
until it receives considerable support from the muscles between it and 
the tibia, render the bone capable of sustaining a somewhat powerful 
force directed against its two upper thirds, without its being fractured. 
The lower extremity of the fibula may be fractured by direct violence, 
or by the outward or inward twisting of the foot, or by the body falling 
to either side, while the foot is confined in a deep cleft ; as occurred in 
the case of Sir Astley Cooper, who says, " I broke my right fibula by 
falling on my right side, whilst my right foot was confined between two 
pieces of ice, and I could with difficulty support myself to a neighbour- 
ing house by bearing on the inner side of the foot." When the fibula 
is fractured in its lower third by direct violence, the situation of the 
fracture is the part to which the violence was applied ; and when the 
fracture has been caused by the inversion or eversion of the foot, it is 
found to be from two to four inches above the lower end of the external 
malleolus. The fibula is not only useful for affording attachment to 
muscles, and assisting to form the ankle-joint, but especially, as it has 
been particularly pointed out by Boyer, for preventing dislocation of 
that joint, in a forced abduction of the foot. It descends along the 
outer part of the astragalus, and he remarked that in every step that is 
made on uneven ground, the foot presses against the inferior extremity 
of the bone. By this action of the foot on the external ankle, the fibula 
is pressed upwards, and as the nature of its articulation with the tibia 
does not allow it to ascend in any perceptible degree, it is compelled to 
bend more or less in proportion to the force applied. The elasticity of 
this bone enables it for some time to resume its natural direction, when 
the force is removed. But as the same force acts frequently, and is 
never intermitted except for short intervals, the bone insensibly acquires 
a permanent bend, instead of being perfectly straight, as it is in the in- 
fant. The bend becomes more evident in proportion as age advances 
and the limb has been used. Climbing animals, such as the squirrel, 
whose feet are always in a very forced abduction, have the fibula very 
strong ; and it has been observed by Cuvier and Dumeril, that in the 
three-toed sloth, the inferior extremity of the fibula is inserted into a 
socket on the superior surface of the astragalus in such a manner that 
the foot must be considerably strengthened by it, and secured against 
dislocation, by the extreme abduction which this animal is obliged to 
make in grasping the trunks and branches of the trees on which he 
climbs. 

Of the two causesof fracture of the fibula from indirect violence, namely, 
violent eversion or inversion of the foot, it is stated by Sir Astley Cooper, 
Mr. Liston, and Professor Samuel Cooper, that eversion is the more 
frequent ; and in this most surgical authorities seem to be agreed ; but 
Baron Dupuytren, in his experience at the Hotel Dieu, found inversion 



188 FRACTURES OF THE BONES OF THE LEG. 

to be more frequently the cause of the fracture. It appears that of two 
hundred cases of broken fibula, a hundred and twenty arose from inver- 
sion or rolling the foot inwards, sixty from eversion or rolling the foot 
outwards, and twenty from direct violence applied to the bone itself. 
When the foot is twisted outwards, the weight of the body, instead of 
following the direction of the axis of the tibia, crosses the lower part of 
the fibula, the ankle-joint, and the malleolus internus in an oblique 
direction ; so that, under such circumstances, it has to be sustained on 
the outer side and above the joint, by the under part of the fibula, and 
on the inner side and below by the malleolus internus, and the internal 
lateral ligaments, while the under part of the fibula is violently pressed 
outwards by the astragalus. When fracture is caused in this manner, 
it is frequently combined with fracture of the malleolus internus, or 
rupture of the internal lateral ligaments. 

When the foot is twisted inwards, the weight of the body, instead of 
following the long axis of the tibia, passes obliquely across the lower 
part of the tibia, the ankle joint, and the malleolus externus, the inner 
aspect of which has the outer part of the astragalus pressed against it, 
while its under extremity is forcibly drawn inwards towards the outer 
part of the foot, by the powerful external lateral ligaments : — the 
rationale of the occurrence of fracture, under such circumstances, may 
be easily understood. 

Symptoms. — There is sometimes considerable difficulty in detecting a 
fracture in the two upper thirds of the fibula, from the bone being 
covered with muscles, and there being no shortening of the limb ; besides 
which, the swelling from infiltration often increases the difficulty of 
tracing the bone, and of detecting crepitus. If the characteristic sign 
of crepitus be perceptible, either on pressing the bone towards the tibia, 
or on pressing the foot violently outwards, — by which means it is some- 
times discovered, or if another characteristic sign be present, namely, 
an unnatural yielding, or mobility of the fibula on pressure, there can 
be no difficulty in forming a diagnosis. In the absence of the above 
characteristic signs, the surgeon will be guided by the following pre- 
sumptive symptoms : — the circumstance of the patient having been sub- 
jected to the only cause of fracture in this situation, namely, direct 
force ; a fixed pain at the situation of the injury ; a crack, or sensation 
of snapping or giving way of the bone having been perceived at the 
time when the injury was sustained, and a difficulty in walking, some- 
times amounting to inability. Pain at the part is generally increased 
on pressing the foot outwards. 

Fracture of the lower part of the fibula is easily discovered. In 
addition to the presumptive signs of fracture, the nature of the injury 
is manifested by an inequality of the bone at the broken part, and unna- 
tural mobility of some portion of the lower end of the fibula ; crepitus, 
perceptible on grasping the leg with one hand, and pressing the foot 
inwards and outwards with the other ; an angular depression at the 
situation of the fracture ; distortion, with some unnatural mobility of 
the foot from side to side, and a change in the point of incidence of the 
axis of the limb upon the foot. Many of these symptoms disappear, 



FRACTURES OF THE BONES OF THE LEG. 189 

when reduction is effected by force applied to the foot, but they return 
when the force is discontinued. 

Nature of Displacement. — In fractures caused by direct violence, or 
by eversion of the foot, the lower extremity of the upper fragment, and 
the upper extremity of the lower fragment, are both drawn inwards 
towards the tibia, so as to diminish the interosseous space ; but in frac- 
tures caused by violent inversion, while the lower extremity of the upper 
fragment is drawn inwards, as in the other varieties, the upper extre- 
mity of the lower fragment is drawn outwards, partly from the manner 
in which the fracture is produced, and partly from the lowest part of 
that fragment being kept inwards by its attachment to the outer side of 
the foot by the external lateral ligaments. A fracture caused by inver- 
sion is usually nearer the malleolus externus, than one occasioned by 
eversion. 

TREATMENT OF FRACTURES OF THE LEG. 

All fractures should be reduced as quickly as possible. To make the 
description of the treatment of these fractures more clear, they may be 
divided into two classes: — first, fractures, whether of the tibia, or of 
both bones, in the upper third ; and secondly, fractures of either or both 
bones, below the upper third. 

I. In fractures of the tibia, or of both bones, which occur in the 
upper third, or even nearly as far down as the middle of the leg, the 
pelvis should be raised, and the limb placed in a straight position. If 
the leg be bent, the quadriceps muscle, by being put on the stretch over 
the articulation, will cause the under part of the upper fragment of the 
tibia to press against the common integument ; and if this should not be 
obviated, there will be great risk of a simple becoming an open or com- 
pound fracture, by ulceration of the integument. In this class of frac- 
tures, therefore, the straight is the preferable attitude. The necessary 
appliances are very simple, and consist merely of a roller to the foot 
and lower part of the leg, to prevent swelling from infiltration ; a hollow 
straight splint of wood, extending from the middle of the thigh to near 
the heel, and two pasteboard or gutta-percha splints for the sides of the 
leg, together with a bandage for retaining the splints in their proper 
place. 

II. In fractures of either or both bones below the upper third, the 
treatment must be different, both as regards attitude and mechanism. 

Attitude. — The preferable attitude, is that in which the leg is bent on 
the thigh, the degree of flexion being greater or less, as is found most 
conducive to the easy retention of the fragments in apposition, and in 
their proper relations to each other, the foot being very slightly 
extended, and neither inverted nor everted. In this attitude, it will be 
more easy than in any other, to prevent the various kinds of displace- 
ment formerly described. 

Mechanism. — Various kinds of mechanism have been invented for the 
treatment of these fractures. The double inclined plane of the late 
Mr. M'Intyre of Newcastle, is an ingenious, elegant, and excellent 
apparatus, and so also is that of Mr. Amesbury, and by means of either 
of them, all the indications to be fulfilled by mechanism, can be readily 



190 



FRACTURES OF THE BONES OF THE LEG. 



accomplished ; but a much cheaper and equally useful apparatus, is the 
splint recommended by Mr. Liston, than which a more convenient piece 

Fig. 40. 




of mechanism for the purposes for which it is intended, could not be 
desired. It consists of a foot-board of wood, and leg and thigh pieces 
of sheet iron joined to each other by a couple of hooks and a screw. 
The screw was in use centuries ago, and is represented in the surgical 
works of Jerome of Brunswycke, published in the sixteenth century. 
By it the thigh and leg pieces may be set to any angle, at which it may 
be desirable to bend the knee, and the foot-piece may be moved upwards 
or downwards, to suit the length of the limb, and fastened by a side 
screw, in any position that may be desired. The splint having been 




adjusted and well padded, the pads being secured by bits of tape, and a 
sock with a piece of tape opposite to the ball of the great toe, having 
been put upon the foot, the limb is placed on the apparatus, and the 
piece of tape attached to the sock is fixed to a knob on the surface of 
the foot-board. The broken ends of the bones having then been placed 
in perfect contact, and in the desired position, the foot, leg, and thigh 
should then be secured by a roller commencing at the toes, and carried 
up so as to embrace the whole of the extremity and apparatus, and also 
to make some turns round the loins. This will prevent the danger of 
displacement from any slight motion of the trunk, and although the 
whole extremity may be moved as one piece, the fragments will always 
preserve the same relations to each other. The bandage should be 
made to pass between the screw and the apparatus, and in carrying it 
round the limb, the greatest care should be taken to adapt it neatly by 



Fig. 40. Liston's cradle. 



Fig. 41. Liston's splint applied. 



FRACTURES OF THE BONES OF THE LEG. 191 

reverses, where inequalities of the limb would cause it to lie unevenly. 
For favouring the return of blood, and diminishing the danger of swell- 
ing, the extremity should be raised a little above the level of the trunk, 
while the patient remains in bed. In general, it is unnecessary to con- 
fine the patient for more than eight or ten days ; after this he may be 
allowed to sit up during most of the day, with the heel on a level with 
the pelvis. The treatment thus goes on pleasantly, without danger of 
the general health being injured by long confinement to bed. By occa- 
sionally turning the screw very slightly, passive motion is given to the 
knee, and the danger of stiffness is obviated. In six or eight weeks, as 
consolidation has advanced, the time for which varies according to the 
age, strength, and constitution of the patient, the apparatus may be 
removed, and the patient allowed to move on crutches : he must be 
careful, however, not to put any weight on the limb for several weeks, 
otherwise, however straight the leg may be, on the removal of the appa- 
ratus, it will become bent and deformed. After the removal of the appa- 
ratus, gentle support should be given to the leg by means of the starched 
bandage, or by pasteboard splints and a common roller. A more con- 
venient or successful method of treatment than the above, need not be 
desired. 

In the absence of the more perfect apparatus, the fragments may be 
preserved in their proper relations to each other by means of the com- 
mon wooden splints for the leg, retained in their position by loop or 
buckle bandages. In fractures of both bones, each splint should have 
a foot-piece ; but in fracture of a single bone, it will be sufficient if a 
foot-piece be attached to the splint on that side to which the foot has a 
tendency to turn. The splints should be well padded with wadding, 
cotton-wool, or tow, to prevent painful pressure on the soft parts. 

[Perhaps the simplest apparatus for fractures of both bones of the 
leg, with the exception of those occurring in the lower third of the 
fibula, is the fracture-box which is used in the Pennsylvania Hospital. 

It consists of a long, narrow box, 
reaching from above the knee to the Fi S- 42> 

sole of the foot. The sides are movable, f^~~\ 
being attached by hinges to the bottom, ' 
and the end of the box is longer than bwv 
the foot, and answers for a foot-piece, w 
The sides of the box are to be opened, and 
a small pillow laid on the bottom, which, 
when the sides are closed, answers the 



purpose of junk or bran bags, adapting itself to the inequalities of the 
limb. The foot is to be secured by a bandage to the foot-board. The 
pressure required to retain the coaptated fragments can be regulated 
by tying several tapes more or less tightly around the box. — Ed.] 

Fractures of either malleolus, or of a single bone, near its lower extremity, 
can be conveniently treated by the simple apparatus so strongly recommen- 
ded, and successfully employed by Baron Dupuytren. When slightly modi- 
fied, it consists of a straight wooden splint, a pad, thicker at the end 
nearest the ankle, and a roller. The splint should be long enough to 
extend from the head of either bone of the leg to three or four inches 
beyond the foot, and have two retiring angles or notches at its extre- 



192 



FRACTURES OF THE BONES OF THE LEG. 



mity, and perforations at its upper end to admit pieces of tape, by 
which a pad is affixed to it, and also to receive the split end of the 
roller. It should be applied to the side of the leg opposite to that to 
which the foot has a tendency to turn, the one extremity extending up- 
wards to near the knee-joint, the other to three or four inches beyond 
the foot. The pad should be between the leg and the splint, with its 
thicker end between the latter and the foot ; and the roller should be 
fixed to the upper extremity of the splint by passing the two parts of 

Fig. 43. 




its split end through the perforations, and securely fastening them 
together. This will prevent the splint from being pressed upwards. 
The roller then, embracing the leg and splint from above downwards, 
should, during its convolutions round the foot, be made to pass through 
the retiring angles or notches in the extremity of the splint, whereby it 
will keep the foot from being displaced in the direction in which it is 
turned by the accident, and the thick end of the pad acting as a ful- 
crum, and keeping the splint removed from the foot, will enable the 
bandage to act with greater effect. In this method of treatment sug- 
gested by Baron Dupuytren, the bandage offers the resistance to dis- 
placement of the foot, and the splint should always be placed on the 
side opposite to that to which the foot has a tendency to turn ; whereas, 
in the treatment with the common splints for the leg, which some British 
practitioners still employ, the splint with the foot-piece offers the resis- 
tance to displacement, and it should always be on the side to which the 
foot is displaced. In the latter method the resistance to displacement 
is offered by the splint with the foot-piece, in the former by the ban- 
dage ; in the latter the splint with the foot-piece is always applied to 
the side to which the foot is displaced, in the former the single splint is 
always placed on the opposite side. 

A most satisfactory way of treating simple fractures of the leg is by 
means of pasteboard splints, together with starch bandage, or by starch 
bandage alone. The period for application is after the subsidence of 
the swelling and slight inflammation that usually follow the injury. A 
great advantage of this method is, that such an incasement is formed 
round the limb as serves to remove all danger of displacement, and 
makes it unnecessary to confine the patient for any great length of 
time to the recumbent posture. Nothing could answer better than this 
mode of treatment, when resorted to at the period mentioned above. 

Fig. 43. From Listen. 



FRACTURE OF THE RIBS. 193 

Of the practice, recently adopted in Belgium, of applying the starch 
bandage immediately after the occurrence of the injury, and thus form- 
ing an incasement for the limb, I have had no experience ; but the 
results are said to be satisfactory, and individuals who have in that 
country witnessed this mode of treatment have given very favourable 
accounts respecting it. 

OPEN OR COMPOUND FRACTURE OF THE LEG. 

Compound fracture of the leg is more frequently met with than any 
other kind of compound fracture. If portions of bone be completely 
detached, they should be removed ; and if the extremity of a fragment 
project through the wound in the soft parts, it should be reduced ; but 
no general rule can be given as to any uniform mode of reduction. 
Sometimes it may be best accomplished by enlarging the wound in the 
soft parts, sometimes by cutting off a portion of the projecting bone 
with a saw or cutting pliers, and occasionally it may be necessary to 
employ both these methods to a certain extent. The surgeon should 
in every instance be guided by the particular circumstances of the case ; 
but in general, if the projecting part of the bone be short and of consi- 
derable thickness, the more judicious procedure is to enlarge the wound ; 
whereas if it be a long slender portion, it would be more advisable to 
cut part of it off. It is only, however, when reduction cannot be other- 
wise accomplished, that the surgeon should have recourse to either of 
these plans. The wound should be cleaned, and its edges brought toge- 
ther, and dressed as the circumstances may suggest ; pressure on the 
part should be carefully avoided, and if abscesses form, they should 
be opened without delay. The local and constitutional treatment must 
be regulated according to the symptoms at the time. 

FRACTURE OF THE RIBS. 

Fractures of the ribs happen almost as frequently as those of any 
other bone in the body. From the statistics of Mr. Lonsdale, it appears 
that, out of one thousand nine hundred cases of fractures admitted into 
the Middlesex Hospital, thirty-five were fractures of the ribs. The 
middle ribs being the longest and most exposed to violence, are most 
liable to fracture. The upper ribs being the strongest, and protected 
by the clavicle and the pectoral muscles, are rarely fractured. The 
lower ribs generally escape injury in consequence of their being short, 
mobile, and free at their anterior extremities. 

Exciting causes. — This accident is produced in one or other of three 
w T ays : — either by direct violence, as a blow, or fall ; or by the applica- 
tion of force to the sternum or anterior extremity of the rib ; or by 
muscular action, as in coughing, in persons of a cachectic habit of body. 
If a rib be fractured by direct violence, the part where the violence was 
applied, is the site of the fracture. If the second exciting cause men- 
tioned produce fracture, the rib gives way at its most convex point — a 
little anteriorly to its angle. 

Symptoms. — A fracture of a single rib, unattended with any internal 
lesion, is an injury of little moment, the patient commonly recovering ^ 
in the course of four or five weeks ; but when several ribs are broken, 

13 



194 



FRACTURE OF THE RIBS. 



and there is, connected with the injury, one or more of the complications 
hereafter specified, the case is one of a very serious nature, and such as 
often terminates fatally. A simple fracture is often capable of detection 
by merely passing the finger over the suspected part. The more elegant 
mode of examination, is to place the hand upon the injured part, and to 
desire the patient to make a full inspiration, or to cough ; when, if a 
fracture be present, a crepitus will be perceived, and the patient will 
experience great pain, from the ends of the bone grating upon the soft 
parts. This latter symptom is much increased by any exertion of the 
respiratory organs, as sneezing, coughing, &c. 

Absence of Thoracic Respiration. — On account of the pain which 
attends the motion of the rib, the patient avoids thoracic respiration, 
and calls into action the diaphragm and abdominal muscles. 

Fig. 44. 




Fig. 45. 




Nature of Displacement. — It is necessary to attend to the direction of 
the salient, or pointed angle. It is obvious that the displacement of 
the ends of the fractured rib can only be either inwards or outwards, 
for the intercostal muscles preclude the possibility of their assuming an 
upward or downward direction. If a rib has been fractured by direct 
violence, the direction of the retiring angle will be outwards, and of the 



FRACTURE OF THE RIBS. 195 

salient angle inwards ; on the contrary, if the injury has been produced 
by violence, applied to the sternum or anterior extremity of the rib, the 
direction of the retiring angle will be inwards, and that of the salient 
outwards : in fact, the disposition of parts is just the reverse. The 
former kind of displacement is the more dangerous, because the pleura 
and lungs are apt to be wounded. If there be a mere fissure, there is 
no displacement. 

Treatment. — This consists in keeping the rib at rest as much as pos- 
sible, by means of a broad bandage of calico or flannel, applied round 
the chest so tight as to stop thoracic respiration, and to make the dia- 
phragm and the abdominal muscles aid in the performance of the respi- 
ratory action. If the ends of the fracture project into the cavity of 
the chest, a large compress is to be applied in front of the sternum, and 
in this manner the convexity of the rib is increased. If they incline 
outwards, the modification of the treatment consists in placing two large 
compresses, one on each side of the fracture. It is convenient, in order 
to prevent the broad bandage from slipping down towards the loins, to 
attach a split cloth, or a scapulary, to its central part posteriorly, and, 
passing it over the shoulders, to secure it in front. Instead of the ban- 
dage already described, a belt of webbing or girth, furnished at one end 
with four or five buckles, and at the other with as many straps, as also 
with two shoulder-straps to prevent displacement, is sometimes employed 
to suspend the movements of the chest in respiration. It is more com- 
pact and effective than the common bandage, and is called a fractured 
rib bandage. To prevent the occurrence of inflammation within the 
chest, it is expedient, if the patient be very plethoric, to take blood from 
the arm. 

PARTICULAR COMPLICATIONS. 

General Emphysema, or inflation of the subcutaneous cellular tissue 
of the body. 

Symptoms. — These are, — difficulty of breathing, a preference of the 
erect attitude to the horizontal, great distension of the cellular mem- 
brane, pitting and crackling on pressure of the swelling, and, if the 
emphysema be very great, a hissing noise on cutting the skin, arising 
from the escape of the air. 

Condition of Parts. — Rupture of the pleura and a portion of the 
lung, from the ends of the fractured rib projecting into the cavity of 
the chest, is necessary to produce this condition. The air is effused 
into the chest, escapes into the cellular tissue around the fracture, and 
by the contraction of the chest in respiration is forced into the general 
cellular tissue, because the air has no outlet, the skin being entire. We 
say, therefore, that general emphysema, in fracture of the ribs, is the 
result of an unnatural communication between the air-cells of the lung 
and the cells of the subcutaneous cellular tissue. If this condition prove 
fatal, it is by way of asphyxia, the great distension of the cellular mem- 
brane mechanically compresses the thorax, so that the muscles of respi- 
ration being overpowered are incapable of dilating the chest. The 
difficulty and imperfection of respiration are indicated by the lividity of 



196 FRACTURE OF THE RIBS. 

the face, lips, and eyelids, the dilatation of the nostrils, and the coldness 
of the extremities for some time previous to dissolution. 

Treatment. — A few deep scarifications should be made over the ster- 
num and the ribs, when the air will escape, and the swelling gradually 
disappear. 

Pneumothorax, or accumulation of air sent from the air-cells of the 
lung into the cavity of the pleura. 

Symptoms. — In a well-marked case, on looking at the thorax, it will 
be observable that the affected side of the chest is longer, from the ribs 
being more or less separated, larger, circular, and almost motionless 
during respiration. Auscultation supplies another symptom, namely, 
the complete absence of the respiratory murmur, except at the roots of 
the lungs, that is, between the scapula and the spine. 

On percussion the affected side yields a clearer sound than the other. 
This symptom, together with the greater size of the affected side, might 
lead one to consider that as the sound, and the healthy as the diseased 
side. 

Treatment. — Generally a slight degree of inflammation takes place, 
which seals up the air-cells, and the air is absorbed. The circulation of 
the lungs should be kept as low as possible, and antiphlogistic remedies 
had recourse to. Sometimes, however, the operation of paracentesis is 
necessary. 

Interlobular Emphysema, or infiltration of air into the cells of the 
cellular tissue of the lung. 

Condition of Parts. — This affection is produced by rupture of some 
of the proper air-cells, and the consequent extravasation of the air con- 
tained in them into the cells of the cellular substance of the lung. The 
cells of the cellular tissue thus distended with air compress the air-cells 
and vessels of the lung, in consequence of which the circulation of air 
through the air-cells, and blood through the pulmonary vessels, becomes 
interrupted, and the portion of lung is rendered incapable of performing 
its function. The air in the cellular tissue does not undergo change ; 
consequently it can have no beneficial effect upon the blood in the lung, 
and by means of the distended cellular tissue, septa form, which isolate 
a portion from the rest of the lung. These septa, by rasping against 
the parietes of the thorax, produce the friction of ascent and that of 
descent, which are indicative of this condition of lung. 

Symptoms. — On exposing the thorax we observe, that the affected 
side is less movable during respiration, not contracting and dilating as 
in the normal state. If the affection be very great there will be a slight 
increase in the length and size of the affected side. 

On percussion over the site of the emphysema, the chest sounds some- 
what more clearly than natural, but not to such extent as in pneuma- 
thorax. The nearer the injury is to the surface of the lung the more 
distinct the resonance will be. Auscultation furnishes another sign 
completely pathognomonic of this affection, namely, the crepitus ronchus 
with large bubbles. This sign, which is more marked during inspira- 
tion than expiration, resembles the noise produced by filling a dried 
bladder with air. Connected with this sign we usually perceive the 
friction of ascent, and the friction of descent, the former accompanying 



FRACTURE OF THE STERNUM. 197 

inspiration, the latter taking place during expiration. The impression 
communicated to the ear is that of some hard dry body, rising and 
falling, and rasping against the thoracic parietes, and is particularly 
discernible just as expiration ends, and before inspiration commences. 
Sometimes this sound is perceptible in the under part of the thorax in 
the neighbourhood of the diaphragm, sometimes in the situation of the 
mediastinum. In some instances this sound is continuous during inspi- 
ration and expiration, in other cases there is a succession of sounds. 
Besides the symptoms already mentioned, there are others of a general 
and local kind, as dyspnoea, more particularly on making any exertion, 
slight lividity of the countenance, coldness of the extremities, and occa- 
sionally emphysema. 

Treatment. — This affection is attended with danger, and all that can 
be done is to preserve the circulation of the lungs as quiet as possible. 
With this view, lay the patient in bed, enjoin low diet and the usual 
antiphlogistic remedies. Sometimes nature seals up the cells with 
lymph, and the air is absorbed and the cellular substance surrounding 
the lobules assume their healthy condition. 

HiEMATHORAX, or effusion of blood into the cavity of the pleura from 
rupture of some of the intercostal vessels, and perhaps of those in the 
substance of the lung. 

Symptoms. — Impeded respiration from obstruction to the motion of 
the lungs, is one of the most marked symptoms of this affection. 

Percussion yields the dull sound, from blood being interposed between 
the thoracic parietes and the lung. The stethoscope indicates the ab- 
sence of the respiratory murmur, except at the root of the lung ; and 
before the effused blood be coagulated, there is sometimes heard a silvery 
sort of echo of a sharp and shrill tone, termed 8egophony, the impression 
communicated being that of a voice heard within the thorax. The voice 
is reverberated in the bronchial tubes, and is conveyed to the surface of 
the chest by the compressed lung and the extravasated blood. The pre- 
sence of a fluid seems to be one of the most essential conditions for the 
production of this phenomenon, consequently it can exist only before the 
blood is coagulated. The features become pale, and all the symptoms 
of internal hemorrhage appear. 

FRACTURE OF THE STERNUM. 

The sternum is sometimes fractured, but not so often as might be ex- 
pected from its exposed situation. It is enabled from its position be- 
tween the elastic cartilages of the ribs to avoid any ordinary violence- 
A fracture of the sternum is sometimes followed with serious conse- 
quences, as necrosis, or abscess immediately behind it. 

Symptoms. — This injury is easily detected by the crepitation which is 
felt on applying the hand to the front of the chest, and desiring the 
patient to make a full inspiration. The function of respiration is prin- 
cipally performed by the diaphragm. 

Treatment. — The patient should be placed in bed, with the head bent 
forwards and the pelvis slightly elevated in order to relax the sterno- 
mastoid and the abdominal muscles. If this be not attended to, an an- 
gular deformity, having the salient angle directed forwards, will result. 



198 FRACTURES OF THE SPINE. 

With the view of keeping the fragments at rest as much as possible, some 
apply a large soap plaster over the ribs, others employ a broad bandage, 
as in fracture of the ribs, which is unquestionably the right proceeding. 

FRACTURES OF THE PELVIS. 

These are of rare occurrence, on account of its peculiar shape and the 
great thickness of several of its bones. 

Exciting Causes. — Falls from a great height upon the pelvis, the 
passage of heavy bodies, as a cart or wagon over it, and falls from or 
under a horse, are the ordinary exciting causes. Of three cases I have 
seen, one was produced by a fall over the ballusters of a staircase from 
the second to the ground-floor ; a second arose from a fall from an em- 
bankment upon a heap of stones ; and the third was a complicated case, 
in which there was dislocation of one of the thigh-bones produced by an 
explosion. Fractures of the ossa innominata, especially if deep-seated, 
are with difficulty detected, but the nature of the injury can generally 
be ascertained from the history of the case, and the inability of the patient 
to support himself in the erect position. There is also a feeling of lace- 
ration at the seat of the injury on the patient making any exertion. 

It often happens as a serious consequence of fractures of the pelvis, 
that the bladder is lacerated and the urine escapes. If the laceration 
be in particular situations, the urine escapes into the peritoneum, speedily 
producing peritoneal irritation and death ; and at other times, and more 
frequently, the urine is effused into the cellular tissue about the pelvis, 
giving rise to sloughing of the parts and extensive abscesses. Fracture 
of the sacrum is often attended with compression of the sacral nerves, 
and consequently with paralysis of the lower extremities. Fracture of 
the os coccygis can be ascertained by careful manipulation, or by intro- 
ducing the finger into the rectum, by which means apposition of the 
parts may be also produced. 

Treatment. — With respect to treatment of fractures of the pelvis, one 
precaution never to be delayed, is the introduction of a catheter into 
the bladder, which should be allowed to continue there a considerable 
time, in order to diminish the danger of extravasation. The patient 
should be placed in a very soft bed, in the easiest position, and the lower 
extremities tied together to prevent any motion. 

If inflammation succeed, it must be combatted by the strictest anti- 
phlogistic treatment the powers of the patient will permit, and after 
some time a broad belt may be placed around the pelvis, so as to keep 
the parts at rest. 

In the union of a fracture of the sacrum, there is sometimes a con- 
siderable quantity of callus thrown out, which may prove inconvenient. 

FRACTURES OF THE SPINE. 

It very rarely happens that one vertebra is broken : two or more are 
generally involved in the injury. The vertebral column contains and 
protects the spinal cord, which gives off the nerves that preside over 
sensation and voluntary motion. 

JUxciting Causes. — These are two : direct violence to the vertebral 
column, and falls from a great height upon the head, the head being at 



FRACTURES OF THE SPINE. 199 

the time bent forwards. When the latter is the exciting cause, the 
appearance presented by the spine is the same as in excurvation, or 
posterior curvature of the spine. 

Symptoms. — These vary very much, and depend upon the situation of 
the fracture and its effects upon the spinal cord. If a fracture take place 
in the lumbar region, and if, in addition to the fracture, there be pres- 
sure upon the spinal cord, arising from displacement, effusion, or extra- 
vasation, there will follow loss of sensation, involuntary expulsion of 
the faeces, retention of urine, together with a sense of pain and weak- 
ness, and a degree of irregularity at the seat of injury. The inability 
of the patient to retain the faeces arises from the sphincter muscle, 
which receives its nerves from the spinal cord, being paralysed. 

Rationale of the Retention of the Urine. — The bladder being para- 
lysed cannot pass off the urine ; hence the retention. This retention 
of urine, as pointed out by Desault, if the patient do not die, is fol- 
lowed by a sort of dribbling, or incontinence of urine. 

The explanation of this latter circumstance is, that the bladder 
becomes so enormously distended, tnat the urine forces open the com- 
mencement of the urethra to such an extent as to allow a small quantity 
to dribble off, yet not sufficiently to relieve the retention or obviate the 
necessity for the introduction of a catheter. A symptom which occa- 
sionally takes place at the time of the injury, is priapism, and even 
emission of the semen, which Mr. Lawrence remarks, has never been 
satisfactorily explained. Notwithstanding the presence of these symp- 
toms, the functions of organic life, as heat, secretion, and circulation, 
still continue. If a fracture with compression occur at the upper part 
of the lumbar region, the whole of the symptoms already mentioned 
will be observed, with the addition of a tympanitic condition of the 
abdomen, produced by the sudden distension of the intestines with gas. 
If the patient do not soon die, this symptom sometimes disappears after 
a smart purging. If a fracture happen in the upper part of the dorsal 
region, together with pressure upon the spinal cord, the additional 
symptom is, absence of thoracic respiration, arising from pressure upon 
the spinal cord above the origins of the intercostal nerves. 

If the fracture be as high up as the sixth cervical vertebra, and 
attended with pressure upon the spinal cord, there is paralysis of the 
superior extremities. 

When a fracture, attended with compression of the cord, takes place 
above the third cervical vertebra, it is instantly fat^. The phrenic 
nerves supply the diaphragm, and instant death is the result of pres- 
sure upon the spinal cord above their origins. The period at which the 
patient dies, varies according to the different situations of the accident, 
and the extent of pressure upon the cord. 

Death is not the immediate result of fracture, even above the third 
cervical vertebra, unless it be attended with displacement. When a 
fracture is lower, down, between the fourth cervical and the first dorsal, 
the patient generally lives from three to ten days. When the dorsal 
region is the seat of fracture with compression, the patient may live 
from two to three weeks. If a fracture occur in the lumbar region, the 



200 FRACTURES OF THE SPINE. 

patient may perhaps live from three to eight weeks, occasionally some 
months, as in a case recorded by Mr. Harold, of Cheshunt. 

Treatment. — Little can be done. The patient should be placed in 
the easiest attitude, and the broken ends of the column preserved at 
rest. Antiphlogistic treatment, both general and local, especially local 
depletion by leeches, may be necessary to prevent and subdue inflam- 
mation. The state of the bladder must be particularly attended to, and 
the catheter introduced, if necessary. If the immediate effects are not 
fatal, counter-irritants may be locally applied, but their use should be 
delayed for some time. 

Concussion of the spinal cord may lead an individual to suppose that 
compression exists when it really does not. Here counter-irritation in 
the chronic stage is very beneficial. The application of strychnine is 
then often attended with the happiest results. The best mode of using 
it is to apply blisters, about the size of a crown-piece, and, when the 
cuticle is removed, to throw one quarter or one half a grain of the 
powder of strychnine over the blistered surface. The operation of tre- 
phining for the purpose of removing pressure from the spinal cord, has 
been proposed and performed : success, however, does not seem to have 
attended the operation, or to encourage a repetition of it. Upon this 
point Sir A. Cooper remarks, " Mr. Henry Cline was the first person 
who attempted to give relief in this accident. Being an excellent anato- 
mist and a most able surgeon, he saw no reason why cases of this kind 
should not be treated as cases of fracture with depression of the skull. 
Accordingly he cut down upon the arch of the spinal marrow, where the 
compression was greatest, and with a small trephine of his own inven- 
tion, he sawed through the arch of the spinous process, and took off the 
pressure on the spinal marrow by raising the depressed portion of the 
arch. 

" It is well known that in cases of fracture, where the displacement 
has been slight, union of the bone has been produced. There would be 
no difficulty in producing this union, supposing the pressure on the spinal 
marrow to be removed. There is a preparation in Mr. Brooks's collec- 
tion, from a case of fracture with depression, where the person lived 
long enough for the fracture to be united ; and in the College of Sur- 
geons there is a preparation, presented by Mr. Harold of Cheshunt, 
from a case where union of the bone took place after fracture with dis- 
placement. There is no danger, therefore, as to the restoration of the 
arch of the bone^if the pressure on the spinal marrow could be removed ; 
and it was with this view that Mr. Cline sawed through the arch. It is 
right, however, to mention that, in many of these cases the spinal mar- 
row is itself torn through. In some cases of fracture, with displace- 
ment, it is completely torn ; in others, partially, and in some not at all. 
In cases where it has not been torn, there would be hope from such an 
operation ; and it is in these cases that the operation has been performed. 
Mr. Tyrrell has attempted the operation since Mr. Cline ; but both 
cases have terminated unfavourably. Whether future experiments may 
be attended with better success, it is impossible to say. The proposal 
was plausible ; the operation was easily performed ; and as to the result 
if the spinal marrow were not torn, there seems no reason why a person 



FRACTURES OF THE SPINE. 201 

should not recover after such an operation. We are obliged, however, 
to speak doubtingly on this subject, since the first experiments have 
been unsuccessful. If you could save one life in ten, ay, in a hundred, 
by such an operation, it is your duty to attempt it, notwithstanding any 
objections which some foolish persons may have urged against it. Sup- 
pose any one present were in this state himself ; suppose him put to 
bed with a paralysis of his lower extremities, and fully acquainted with 
the inevitable result if nothing were done ; would he not be glad to have 
an attempt made to save him ? Would it not be foolish and unmanly to 
say he would rather die than have such an attempt made ? The opera- 
tion is not severe ; it cannot add to his danger ; and as to the pain, no 
man is a man who would regard it. In the two cases in which the 
attempt was made, the operation did not shorten life ; on the contrary, 
there is reason to believe that it prolonged it. You will be justified, 
therefore, in making the attempt. Though I may not live long enough 
to see the operation frequently performed, I have no doubt but it will 
be occasionally performed with success. There is no reason why it 
should not; and he who says that it ought not to* be attempted is a 
blockhead." — Sir A. Cooper's Lectures on Surgery, pp. 152, 153. 

"It has been proposed," Mr. Liston observes, "to treat the spine, in 
cases of severe and alarming fracture, in the same manner as the cra- 
nium, by trephining ; and some have recommended this in almost all 
kinds of injuries. I allude to the practice, only to condemn it. The 
spinal cord is generally displaced and compressed by the lower portion 
of the fractured body of the bones. One cannot easily comprehend 
what an operation is to effect in such cases : further notice of this pro- 
ceeding is unnecessary, seeing that, as far as I know, it has been unani- 
mously discarded by the profession from amongst the list of surgical 
operations." — Liston's Elements of Surgery, second edition, p. 697. 
" The great objection," says Mr. Lawrence, " to this proceeding is, the 
uncertainty respecting the precise seat of injury, and the precise mode 
in which the spinal cord has been injured, or continues to suffer pres- 
sure. This operation of exposing and taking away part of the vertebral 
column, is really a very serious, and I may say, a very delicate affair ; 
it is an operation which, if it were done when the contents of the spinal 
canal were perfectly uninjured, would, I think, be likely to be followed 
by inflammation of the membranes and cord ; it would be likely to pro- 
duce mischief, even if no mischief had existed before. For these various 
reasons it appears to me that the proposal of taking out the spinous 
processes of one or two of the vertebrae ought not to be entertained." 



202 



CHAPTER VI. 
INJURIES OF THE HEAD. 

FRACTURES OF THE CRANIUM. 

Causes. — From the manner in which the different bones of the cra- 
nium are arranged, an ovate or spheroidal box is formed, which resists 
external violence, after the manner of arches, according to Bertin, and 
of spheres according to Beclard ; yet it is frequently fractured, and in 
the majority of instances these fractures are produced by the direct 
application of force to the injured part, as when a person is struck, or 
falls upon the head, and the bone is broken exactly where the blow or 
fall was inflicted. The cranium, however, does not always give way 
where it was struck, but sometimes at a distant part, forming the frac- 
ture by counter-stroke of the British, the fracture par contre-coup of the 
French authors. 

Fractures of the base of the cranium, in the great majority of in- 
stances, are caused by counter-stroke ; the reason of which is easily 

explained. If a great weight fall upon 
Fig- 46. the top of the head while the body is 

erect, or if the top of the head be struck 
by an obtuse body, the force thus applied 
above has a tendency to produce expan- 
sion of the lateral parietes, and to force 
the base of the cranium against the apex 
of the spinal column. It is evident that 
in such circumstances the cranium is acted 
upon by two forces : the violence applied 
to the top of the head acting downwards, 
and the resistance offered by the vertebral 
column acting upwards, so that a fracture 
of the base is often the result. In like manner, when in falling from a 
great height, the top of the head or vertex comes to the ground, the 
resistance of the ground acts on the top of the head, and the whole 
momentum acts through the medium of the spinal column on the base. 
The cranium, being thus included between two forces, gives way at its 
weakest part, that part being the base. Sometimes, however, fractures 
of the base are produced without a fall or blow on the head itself, as 
when a person falling from a great height alights upon the nates ; the 
spinal column being thus brought suddenly into a state of rest, offers 

Fig. 46. Fracture across whole base of the skull, produced by a fall on the crown 
of the head. The patient was admitted into my wards in the Royal Infirmary. From 
a preparation in my museum. 




FRACTURES OF THE CRANIUM. 203 

resistance to the head, which being still in projectile motion, has its 
base forcibly driven against the spine, and a fracture may be the result. 
In each of these three cases, the head is acted upon by two forces with 
greater or less violence. 

Sir Benjamin Brodie, in a very interesting paper on Injuries of the 
Brain, in the fourteenth volume of the Medico-Chirurgical Transactions, 
says at p. 329, — " It has been observed to me, however, by Mr. Earle, 
that he has not known a fracture of this kind (i. e. by counter-stroke), 
to take place, except when the blow seems to have operated in such a 
manner as to impel the occiput forcibly against the atlas, the line of 
fracture passing through the former bone, where it rests on the latter. 
My own experience corresponds very nearly with that of Mr. Earle. 
The only well-marked cases of fracture of the cranium, in which the 
fracture could be attributed to the effects of contre-coup, which have 
fallen under my observation, were similar to those he has mentioned. 
I do not, however, mean to assert that such fractures absolutely never 
occur, independent of the reaction of the atlas. Among the cases re- 
corded in the Prize Memoirs of the French Academy of Surgery, there 
are some which show that the thing does happen ; and Mr. Bell has 
afforded an ingenious and scientific explanation of the mode in which it 
happens. It is, however, worthy of remark, that the only two cases 
which Mr. Bell has adduced in illustration of what he has advanced, 
are those in which the fracture extended across the occiput, in the one 
passing through, in the other close to the foramen magnum of that 
bone." 

Fractures of the base of the cranium are not invariably caused by 
counter-stroke. Sometimes, when violence is directly applied to the 
occiput or the lateral parts of the cranium, it is not only sufficient to 
produce fracture of the part to which it is applied, but also to extend 
the fracture to the base. Of this I have seen two instances : — one, in 
which the fracture extended forwards to the body of the sphenoid bone, 
in consequence of a fall on the occiput, and the other, in which it ex- 
tended along the whole base of the skull, in consequence of a kick from 
a horse on the mastoid process. 

Of fractures of the cranium it may be observed, that those of the base 
in most instances result from counter-stroke, while those in other situa- 
tions are invariably occasioned by direct violence. 

ARRANGEMENT OF FRACTURES OF THE CRANIUM. 

These fractures present every possible variety of form, from the most 
simple fissure to the most complicated fracture extending in many direc- 
tions, and accompanied with depression. The ancient writers divided 
fractures of the . cranium into many different varieties, distinguishing 
each by an appellation descriptive of its form, or of some peculiarity in 
the relation of the fractured parts ; but these appellations, as they bur- 
dened the memory without leading to any useful practical results, are 
now abandoned. To show clearly the views now entertained respecting 
the nature and treatment of these injuries, it will be convenient to 
arrange them in the following six classes. First, Simple fissure, or 
fracture unattended with depression. Second, Simple fracture with 



204 FRACTURES OF THE CRANIUM. 

depression. Third, Punctured fracture.. Fourth, Compound or open 
fracture. Fifth, Fracture of the external table alone ; and Sixth, 
Fracture of the internal table alone. 

I. SIMPLE FISSURE, OR FRACTURE UNATTENDED WITH DEPRESSION. 

As in this injury there is no wound in the soft parts, and the broken 
pieces preserve their proper level or equality of surface, and as the 
simple interruption to continuity of the bone produces no symptom de- 
noting its presence, it often escapes detection, and continues during life 
a matter of uncertainty. Simple fracture, considered in itself, is by no 
means a dangerous injury, and when its existence is suspected, and there 
is no accompanying injury of the parts within the cranium, it is not 
necessary to do more than enjoin every prudent precaution against the 
occurrence of inflammation. The violence which breaks the bone may 

give rise to separation of the 
Fi g- 47. dura mater, laceration of the 

brain, extravasation of blood 
within or upon the brain, or 
above or below the dura mater, 
or to simple fissure of the outer 
table and fracture with depres- 
sion of the inner; and in con- 
sequence of some of these ac- 
companying conditions within 
the head, there may be con- 
cussion immediately after the 
injury, or the symptoms of compression or of inflammation of the brain 
or its membranes may appear, with all their usual consequences, to a 
dangerous or even fatal extent. The treatment of these conditions will 
be afterwards described. 

II. SIMPLE FRACTURE WITH DEPRESSION. 

The local signs of this injury are, — an inequality of the surface of 
the cranium, varying in extent according to the amount of depression, 
and usually the appearance of a bruise of the scalp. Sometimes the 
fragments are movable ; in other instances the depressed portion is 
quite unyielding. There is a condition of scalp, frequently presenting 
itself after a contusion, more especially if inflicted by a flat body, which 
is very deceptive, and apt to make the inexperienced observer suppose 
that the depression of bone is to a much greater extent than it really 
is, and even to produce the impression that the bone is driven in, when 
no fracture really exists. I refer to the swelling caused by extravasa- 
tion. Into the cellular tissue surrounding the contusion blood becomes 
extravasated, and this raises up the soft parts to a considerable extent, 
whereas, at the bruise itself, if the contusion has been severe, the soft 
parts remain compressed in consequence of the cellular tissue having 
been deadened and the vessels paralysed by the bruise. The swelling 

Fig. 47. Simple fissure of cranium, produced by a fall on the side of the head. The 
case occurred in the experience of my colleague, Dr. Dyce. From a preparation in my 




FRACTURES OF THE CRANIUM. 



205 



Fin;. 48. 




is remarkably firm, and the impression given to the finger by the extra- 
vasated blood so closely resembles that given by the margin of a frac- 
tured portion of bone, that it is very likely to deceive an unguarded 
observer. This condition of 
the soft parts should be al- 
ways kept in mind, lest the 
surgeon be deceived, either 
into the supposition that 
there is depression where 
none exists, or into the opi- 
nion, when it is present, that 
it is to a greater extent than 
is really the case. If the 
injury be not inflicted by a 
flat body, the whole of the 
scalp may be elevated at the 
injured part. Extravasation 
may be found in three dif- 
ferent situations, namely, 
between the integument and 

the tendon of the occipito-frontalis muscle, between the occipito-frontalis 
muscle and the pericranium, or between the latter and the bone. 
Besides the local appearances here described, fracture with depression 
may be attended with the usual symptoms of compression of the brain ; 
for an account of which I must refer the reader to the chapter on Com- 
pression. 

In regard to these symptoms, the intelligent surgeon will not only 
keep in mind the different conditions on which they depend, but in order 
to arrive at a correct diagnosis, and to ascertain from which of the 
various different conditions the symptoms in any particular case may 
proceed, he will inquire very minutely into the history of their appear- 
ance. Compression of the brain, proceeding from external injury, may 
be occasioned by a depressed portion of bone, or extravasation of blood, 
or the formation of purulent matter. The time when the symptoms 
made their appearance, will be found the surest guide in determining to 
which of these three causes they are to be attributed. When a depressed 
portion of bone occasions the compression, the symptoms present them- 
selves from the very occurrence of the injury ; when extravasation of 
blood is the cause, the symptoms do not appear immediately, except 
sometimes in a very slight degree, and it is not until a considerable 
quantity of blood has collected, that they show themselves very deci- 
dedly. When a patient, having been stunned by an injury of the head, 
recovers from the. stun, and symptoms of compression afterwards appear 
and gradually increase, there is then reasonable ground for supposing 
that they arise from effusion of blood. When the compression is caused 
by the formation of matter, it does not appear for several days, and is 
preceded by the symptoms of inflammation of the brain, or its mem- 
branes. Thus the history of the symptoms is a useful guide in deter- 
mining the cause on which the compression depends. It is important 



Fig. 48. Fracture of cranium with depression. From a preparation in my museum. 



206 FRACTURES OF THE CRANIUM. 

to remember that the injury of the one table scarcely ever corresponds 
with that of the other, the inner being almost always fractured to a 
greater extent than the outer, and the actual depression of the inner 
table being much greater than would appear from the examination of 
the outer part of the cranium. It is a remarkable fact, but one of which 
the records of surgery furnish many examples, that there is no certain 
correspondence between the symptoms of compression, and the extent 
to which a portion of the bone may be depressed. In some instances 
where the depression has not been to a great extent, the symptoms have 
been decidedly marked ; in others, the symptoms have been very slight, 
when the depression has been manifest and considerable. Hence the 
statement of an eminent modern writer, "It is extraordinary and unac- 
countable, but it is not less true, that no calculation of the bad effects 
can be made, by the degree to which a part of the skull is depressed." 
Several very interesting cases confirmatory of this fact will be found in 
Thomson's Observations made in the military hospitals in Belgium. 

Treatment. — The object to be aimed at by treatment varies accord- 
ing to the presence or absence of the symptoms of compression. In the 
absence of these symptoms, the indication of treatment is to prevent the 
occurrence of inflammation, and for that purpose the strict antiphlogistic 
regimen, consisting of low diet, rest, and quietude, should be enjoined. 
It is also advisable to shave the head, to keep it cool by means of cold 
applications, to administer some smart purgative, and in some habits of 
body, it is prudent, even as a precautionary measure, to have recourse 
to depletion, provided there be much reason to apprehend inflammatory 
action. It would, however, be extremely injudicious to have recourse 
to depressing treatment in the period of collapse which immediately suc- 
ceeds such an injury ; and after this period is passed by, the extent to 
which this treatment ought to be carried should be regulated by the age, 
habits, and constitution of the patient, and the particular circumstances 
of the case. 

If symptoms of depression be present, then the immediate object to 
be aimed at, is to relieve the brain from pressure ; and the means to be 
taken, in the first instance, for that purpose, will depend on the extent 
of the depression, and the urgency of the symptoms. If the bone be 
not depressed to a very great extent, and if the symptoms be not ex- 
tremely urgent, the attempt should first be made to relieve the pressure 
of the brain by bleeding, purging, and the constant application of cold 
to the head after it has been shaved. Under this alleviating treatment, 
the brain sometimes becomes accommodated to its new condition, and 
the symptoms disappear. If after the proper measures have been em- 
ployed for a moderate period, the symptoms still continue, then the de- 
pressed portion of bone must be elevated. But if the depression be not 
only manifest, but also to a great extent, and the symptoms of compres- 
sion be very strongly marked, then the surgeon is justified in elevating 
the depressed portion of bone without waiting to ascertain the effect of 
the alleviating treatment recommended above. It appears, then, that in 
this variety of fracture, the circumstances under which the surgeon is 
warranted in proceeding to operate, are, — either when the symptoms 
continue unabated after the judicious employment of bleeding, purging, 



FRACTURES OF THE CRANIUM. 



20T 



49-54. 



and the constant application of cold to the head ; or, without waiting 
for the employment of these remedies, when the symptoms are alarm- 
ingly urgent, and the bone depressed to such an extent as to leave no 
hope of the brain becoming accommodated to its unnatural condition. 
When, in either of these cases, the surgeon has resolved to elevate the 
depressed portion of bone, Jie should first expose the fracture by making 
a crucial incision, and then raise up the bone by means of some of the 
different forms of elevators used for that purpose. If, as is often the 
case, it should be impossible to introduce the elevator underneath the 
depressed portion, the surgeon is justified in trephining, his object 
being, not to saw out the depressed 
portion, but to remove a part of the 
bone which is not depressed, so as 
to admit of the introduction of the 
elevator, by which the depressed 
part may be raised to a level with 
the surrounding parts of the cra- 
nium. 

I cannot conclude this chapter 
without referring to a most extra- 
ordinary case, which shows, that at 
a very distant period from the ac- 
cident, the symptoms of compres- 
sion maybe removed and the patient 
restored to his ordinary powers of 
body and mind. The case seems 
to have produced a deep impres- 
sion on the mind of Sir Astley 
Cooper, who records it in the fol- 
lowing words : — " The other cir- 
cumstance which I shall mention, 
is one, which, whether we regard 
it in a physiological or surgical 
point of view, is perhaps one of the 
most extraordinary that ever oc- 
curred ; and, as connected with 
surgery and physiology, I am sur- 
prised it has not made a greater 
impression on the public mind than 
it appears to have done. A man 
was pressed on board one of his 
majesty's ships, early in the late 
revolutionary war. While on board 
this vessel in the Mediterranean, 
he received a fall from the yard- 
arm, and when he«was picked up 
he was found to be insensible. The 
vessel soon after making Gibraltar, 
he was deposited in an hospital in that place, where he remained for 
some months still insensible, and some time after he was brought from 





208 FRACTURES OP THE CRANIUM. 

Gibraltar on board the ' Dolphin' frigate to a dej)ot for sailors at Dept- 
ford. While he was at Deptford, the surgeon under whose care he was, 
was visited by Mr. Davy, who was then an apprentice at this hospital. 
The surgeon said to Mr. Davy, ' I have a case which I think you would 
like to see. It is a man who has been insensible for many months ; he 
lies on his back with very few signs of life ; he breathes, indeed, has a 
pulse, and some motion in his fingers ; but in all other respects he is 
apparently deprived of all powers of mind, volition, or sensation.' Mr. 
Davy went to see the case, and on examining the patient found that 
there was a slight depression on one part of the head. Being informed 
of the accident which caused this depression, he recommended the man 
to be sent to St. Thomas's Hospital. He was placed under Mr. Cline, 
and when he was first admitted into this hospital, I saw him lying on 
his back, breathing without any great difficulty, his pulse regular, his 
arms extended, and his fingers moving to and fro to the motion of his 
heart, so that you could count his pulse by this motion of his fingers. 
If he wanted food he had the power of moving his lips and tongue ; and 
this action of his mouth was the signal to his attendant for supplying 
his wants. Mr.. Cline, on examining his head, found an obvious depres- 
sion ; and thirteen months and a few days after the accident he was 
carried into the operating theatre and there trephined. The depressed 
portion of bone was elevated from the skull. While he was lying on 
the table, the motion of his fingers went on during the operation ; but 
no sooner was the portion of bone raised than it ceased. The operation 
was performed at one o'clock in the afternoon. And at four o'clock as 
I was walking through the wards, I went up to the man's bedside, and 
was surprised to see him sitting up in his bed. He had raised himself 
on his pillow ; I asked him if he felt any pain, and he immediately put 
his hand to his head. This showed that volition and sensation were 
returning. In four days from that time the man was able to get out of 
bed, and began to converse ; and in a few days more he was able to tell 
us where he came from. He recollected the circumstance of his having 
been pressed, and carried down to Plymouth or Falmouth ; but from 
that moment up to the time when the operation was performed (that is, 
for a period of thirteen months and some days) his mind remained in a 
state of perfect oblivion ; he had drunk, as it were, the cup of Lethe ; 
he had suffered a complete death, as far as regarded his mental, and 
almost all his bodily powers, but by removing a small portion of the 
bone with the saw, he was at once restored to all the functions of his 
mind, and almost all the powers of his body. It appears, therefore, 
that in cases of depression we should not be prevented from trephining, 
however distant the period may be at which the accident occurred, and 
the patient may, after any interval, be restored to the powers of body 
and mind." 

III. PUNCTURED FRACTURE. 

When a fracture is caused by a sharp body, such as a corner of a 
stone, or by any pointed instrument, such as a bayonet or a pitchfork, 
or by a sharp-pointed body of any kind, which applies force with con- 
centrated effect, it usually presents the appearance of a cavity, or mere 



FRACTURES OF THE CRANIUM. 



209 



Fig. 55. 



puncture, and is hence called a 
punctured fracture ; and because 
there are often numerous fissures 
radiating on every side from the 
centre, it is also called star-like or 
radiated fracture. From the man- 
ner in which such a fracture is oc- 
casioned it is often attended with a 
wound of the soft parts. The in- 
ternal table is, on account of its 
brittleness, injured to a greater ex- 
tent than the external, and there 
is one circumstance in this form of 
fracture which renders it so exceed- 
ingly dangerous as to require imme- 
diate recourse to an operation, even 
in the absence of compression, or of 
every bad symptom. This circum- 
stance is, that spicular portions of the internal table are always driven 
inwards, and if these be not removed, it is almost certain that inflamma- 
tion will be excited, and if so, the ordinary remedies will have no effect, 
while the exciting cause continues ; and if the operation be delayed 
until inflammation has taken place, it will then be too late to save the 
patient. In short, the very existence of this form of fracture impera- 
tively calls for an operation. On exposing the fracture the depressed 
portions should be raised ; and if it be impossible to introduce the ele- 
vator or forceps, it will be necessary to remove a small part of the sound 
portion of the cranium for the admission of the instrument. After the 
cause of irritation has been removed, and the edges of the wound been 
approximated, the treatment will consist of the rigid institution of anti- 
phlogistic regimen to prevent inflammation, and to subdue it in case of 
its occurrence. 




IV. COMPOUND OR OPEN FRACTURE WITH DEPRESSION. 

On this important subject, Sir Astley Cooper remarks, " Compound 
fracture is followed very generally by inflammation of the brain, and it 
will be of no use to trephine, when inflammation is once formed. It 
might be thought that it would be time enough to perform this operation 
when inflammation had appeared ; but this is not the case ; for if inflam- 
mation comes on, the patient will die, whether you trephine or not ; and 
you will be so far from arresting its final progress by trephining that the 
operation will add to the danger of the inflammation. When inflamma- 
tion of the dura mater and membranes has been excited by depression 
of the bone, you cannot retard the progress of death by performing the 
operation." 

Sir Astley Coop'er enforces these principles by cases, and concludes 
by saying, " The elevation of the bone is never followed by any mis- 
chief; but if you do not raise it, and inflammation follows, it will be 



Fig. 55. 



From Liston. 
14 



210 FRACTURES OF THE CRANIUM. 



[LIS 



too late to attempt to save the life of the patient." In reference to this 
doctrine laid down by Sir Astley Cooper, Sir Benjamin Brodie, aftei 
referring to the fact that many persons undoubtedly have recovered, in 
Avhom there was at the same time a wound in the scalp and a fracture 
with depression of the cranium, although no operation was performed, 
and after referring to examples published by Mr. Abernethy, and various 
cases which occurred at the battle of Talavera de la Reyna, and were 
communicated by Mr. Rose, Surgeon to the Coldstream Regiment of 
Guards, goes on to say, " I have conversed also with other surgeons, 
whose experience has compelled me to doubt the accuracy of Sir Astley 
Cooper's conclusion. The question, however, is not to be decided merely 
on these premises. Many persons may do well without an operation, 
who suffer from what Sir Astley Cooper denominates a compound frac- 
ture of the cranium, and yet it may remain to be determined what is 
the probability of suppuration taking place in these cases as compared 
with those in which the scalp remains uninjured. For many years I 
have preserved notes of a large proportion of the cases of injury of the 
head, which it has fallen to my lot to witness. Among them, of course, 
are many in which there was fracture with or without depression, fol- 
lowed by suppuration between the dura mater and the bone. On refer- 
ring to these for further evidence on this interesting subject, I find that 
the cases in which suppuration takes place where the scalp is entire, 
have been comparatively rare ; bearing a very small proportion indeed 
to those cases in which suppuration has followed a fracture complicated 
with a wound of the scalp. Such is the result of my own experience 
during a considerable period of time, and which I am enabled to give, 
not merely from a general recollection of what I have seen, but on the 
authority of written notes, made at the bedside of the patients, and, for 
the most part, before the question which they illustrate had ever pre- 
sented itself to my mind. Taking all these facts into consideration, 
and endeavouring to give its proper value to what may be urged on 
either side of the question, I cannot but acknowledge, whatever may 
have been my first impression on the subject, that it appears to me at this 
moment that the views of Sir Astley Cooper are well founded, and that 
in those cases in which a depression of bone exists, without any symp- 
toms, or with only very trifling symptoms, arising from it, the surgeon 
can follow no better general rule than this ; if the depression be exposed 
in consequence of a wound of the scalp, let him apply the trephine, and 
elevate the depression ; but if there is a depression without a wound of 
the scalp in consequence of the accident, let him not make such a wound 
by an operation." 

From the above, it will be evident that the views of Sir Astley 
Cooper, as to the necessity" of trephining in compound fracture with 
depression, in the absence of any symptoms of pressure, received, after 
much deliberation, the decided approval of Sir Benjamin Brodie. A 
different opinion, however, is maintained by many surgeons ; and Pro- 
fessor Samuel Cooper, as will appear from the following extract from 
his lectures, seems inclined to agree with those who do not recommend 
an operation, except when symptoms of compression are present. In 
speaking of the doctrine laid down by Sir Astley Cooper, he say*, " I 



FRACTURES OF THE CRANIUM. 211 

cannot say that the observations which I have had opportunities of 
making on this point of surgery, would have led me to adopt this opi- 
nion." Sir Philip Crampton remarks on this subject, "In Dublin we 
conform in general to the rule of practice originally laid down by Dease, 
who preceded Desault by many years, namely, in fractures of the skull 
with depressed bone, whether complicated by wound of the scalp or other- 
wise, no attempt should be made to raise the depressed bone, unless 
very decided symptoms be present of compressed or irritated brain.'' 

Sir P. Crampton mentions that he has seen many cases terminate 
very favourably without the trephine, and refers to some in the very 
interesting paper in which he states the above views. On this point it 
will be evident that Sir P. Crampton and Professor Samuel Cooper are 
agreed, and that their opinion is opposed to that of Sir Astley Cooper 
and Sir Benjamin Brodie. Some surgeons are of opinion that in the 
absence of compression, trephining is justifiable only when the compound 
fracture partakes of the nature of punctured fracture ; and others, that 
the surgeon should be guided by the extent of the depression, the con- 
dition of the fragments, and the possibility of elevating them without 
increasing the wound of the scalp. For my own part, as Sir Astley 
Cooper's opinion is given with so much decision, and is founded on so 
extensive an experience, I should very much hesitate to advise any 
different procedure. 

V. FRACTURE WITH DEPRESSION OF THE EXTERNAL TABLE. 

Fracture of the external table, with depression into the diploe', can- 
not take place either in early life or frequently in old age, as the skull 
is, at both these periods, comparatively thin and without diploe ; but 
that it has taken place in the middle period of life, is no longer a 
matter of uncertainty. This condition of the external table, the internal 
remaining at the same time perfectly entire, has now been demonstrated 
by many specimens, in which the occurrence of reunion proves that the 
patients must have lived for some time after the injury. The possibility 
of this condition suggests the propriety of caution in forming a diagnosis, 
and furnishes a reason why mere depression of a part of the cranium 
does not, if unaccompanied with compression, warrant the performance 
of trephining. 

If unattended with concussion, this injury is not likely to lead to any 
serious consequences, nor does it require any treatment beyond the 
precautions proper to be attended to, after every kind of injury about 
the head. 

VI. FRACTURE WITH DEPRESSION OF THE INTERNAL TABLE. 

The records of surgery furnish various examples of this fracture, 
every instance of which, attended with unfavourable symptoms, must 
form a case of great anxiety and difficulty to the surgeon. Professor 
Samuel Cooper records a case of this Jdnd, with urgent symptoms, in 
which he performed the operation of trephining at Brussels, after the 
battle of Waterloo. The external table was perfectly entire, but a 
large splinter of the inner was driven more than an inch into the brain, 
and on its removal the patient's senses and power of voluntary motion 



212 FRACTURES OF THE CRANIUM. 

returned. The part of the skull to which the trephine was applied, did 
not, of course, present any depression, and it was selected because the 
appearance of the scalp showed that there the external violence had 
been inflicted. In Dr. Hennen's Military Surgery, a case is recorded 
in which the external table was entire, and the internal splintered and 
driven more than half an inch into the brain. 

If a patient has been struck, or has fallen upon a certain part of his 
head, and if the external table be entire, and the symptoms of compres- 
sion supervene, the difficulty of diagnosis is sometimes very great, for 
the history of the symptoms is almost the only guide to the surgeon in 
forming a conjecture as to whether the symptoms be caused by depres- 
sion of the internal table, by extravasation of blood, or by matter ; and 
yet it is sometimes impossible, from the history, to arrive at a decided 
opinion, because although it is true that in depression the symptoms 
which indicate the state of the brain come on immediately after the 
injury, and in extravasation, some time elapses before they appear, and 
they become more distinctly marked as the blood is effused from the 
ruptured vessels ; still, in a case of extravasation, the patient may have 
been insensible in the first instance from being stunned, or from the 
concussion of the brain, and before the insensibility from this cause 
has worn off, insensibility from compression may have come on ; in such 
a case, the patient having been insensible from the very occurrence of 
the injury, it would be impossible to determiue whether the compression 
has been caused by extravasation, or by fracture with depression ; and 
accordingly we find that in some successful cases, in which trephining 
was performed, in the expectation of finding the cause of pressure to 
be blood extravasated under the cranium, it turned out to be fracture 
with depression of the inner table. But supposing the injury of the 
internal table has given rise to extravasation of blood, or the formation 
of matter, although the surgeon should think that there is little doubt 
which of these is the cause of the symptoms in any particular case, still 
he has no certain guide as to the precise seat of the collected matter ; 
he has no decided and unequivocal symptom to enable him to determine 
whether the blood be above or below the membranes of the brain, and 
consequently the real nature of the case, and the exact condition of the 
patient, must be very uncertain, and the indications of treatment ex- 
tremely doubtful and precarious. It would be saying too much to affirm 
that in every instance the surgeon should confine himself to the use of 
the alleviating remedies for pressure, formerly enumerated, and that 
what has very appropriately been called " exploratory trephining" 
should never be performed in any case. The case in which the indica- 
tion of treatment would be most clear, and the operation, if ever ad- 
visable, most warranted, is where symptoms of compression come on 
after an injury in the situation of the middle meningeal artery. On 
this subject Sir Benjamin Brodie remarks : — " Where no fracture is 
discovered, yet if there is other evidence of the injury having fallen on 
that part of the cranium in which the middle meningeal artery is situ- 
ated, the use of the trephine may be resorted to on speculation, rather 
than that the patient should be left to die without an attempt being 
made for his preservation. I cannot indeed adduce any particular 



CONCUSSION OF THE BRAIN. 213 

experience of my own in favour of what is here recommended ; but I con- 
ceive that the instances which have been recorded, in which the middle 
meningeal artery has been ruptured without any fracture of the bone, 
and the known fact that there is sometimes a fracture of the inner 
table, sufficiently justify such an experiment in desperate cases, or even 
in those in which there is much danger." 

On the very important and interesting subject of fractures of the 
cranium, I must limit myself to the above observations ; but at the con- 
clusion of the chapter on Compression of the brain, will be found an 
enumeration of the conditions, in which, according to the views now 
entertained regarding the treatment of injuries of the head, the opera- 
tion of trephining is considered advisable. 

CONCUSSION OF THE BRAIN. 

Causes. — The injury which is termed by British authors " Concussion 
of the Brain," by French, " Commotion," and in common parlance 
" stunning," is produced by one or other of the three following causes : 
— a blow, or a fall, on the cranium itself, or a fall from a considerable 
height on some other part of the body, as the buttocks, or the feet, by 
which a sudden shock is communicated to the brain, through the medium 
of the vertebral column. I lately had under my care a mason, in whose 
case there were strongly-marked symptoms of concussion, caused by his 
falling from the second floor of a house on his buttocks ; and I am at 
present attending a female, who, in consequence of the horse becoming 
restive, jumped from the top of a cart loaded with hay, and alighting 
on her feet sustained fracture of one leg, and concussion of the brain. 
The spine in these circumstances is suddenly brought into a state of 
rest, and the head being still in projectile motion, is forcibly struck 
against the summit of the vertebral column : the sudden jerk thus com- 
municated to the brain occasions " concussion." 

Symptoms. — For facilitating the description of the symptoms of con- 
cussion, it will be convenient to adopt Mr. Abernethy's arrangement of 
them into three stages ; an arrangement not only advantageous for pro- 
moting a clear understanding of the symptoms, and for reconciling by 
accurate discrimination some of the various descriptions of them given 
by previous writers, but valuable also, together with his other observa- 
tions, as having led to more correct and scientific views of practice than 
formerly prevailed. By referring to his Surgical Observations on 
injuries of the head, it will be found that he arranged the symptoms 
into three stages, which he called the first, second, and third. The first 
stage, which immediately follows the injury, is one of collapse, in which 
there is insensibility, with derangement of bodily powers ; the second is 
one of reaction, in which there is, to a greater or less extent, some return 
of sensibility, and restoration of bodily powers ; and the third is one of 
inflammation of the brain, indicated at first by increased excitement of 
that organ, and increased vascular action ; and this stage is certainly 
not the least important of the series of consequences which result from 
concussion. 

In well-marked examples the different stages are characterized by the 
following symptoms. 



214 CONCUSSION OF THE BRAIN. 

In the first stage, the operations of mind are in many instances sus- 
pended, and often to such an extent, that consciousness is entirely lost 
for the time ; the functions of the brain and of the organs of sense are 
also suspended, so that there is complete insensibility to all external 
impressions. Common sensation and voluntary motion are also lost for 
the time ; and often the loss of sensation is so great, that the patient 
gives no indication of being pained, on pinching or irritating the skin ; 
in short, he does not feel any injury inflicted on him ; and with regard 
to motion, it does not so much seem to be the power of contractility that 
is lost, as the power of voluntarily combining the action of the muscles, 
so as to perform any particular movement. The operations of mind, 
and the powers of sensation and of voluntary motion, are usually sus- 
pended together, but I have seen instances in which the loss of the one 
is greater than that of the other ; and Sir Astley Cooper records a well- 
marked example in a gentleman, who at one time, in the absence of his 
attendant, got out of bed, bolted the door, passed water, and went to 
bed again, and yet he was so insensible, that every attempt to get a 
word from him was ineffectual, and Sir Astley Cooper says, he does not 
believe the noise of an earthquake would have succeeded in rousing him 
from his lethargy. The countenance is pale and collapsed ; the surface, 
especially at the extremities, cold ; the respiration is by some observers 
said to be easily and naturally performed ; in slight cases, certainly, it 
is almost natural, but in such as are well marked, it is very feeble and 
without stertor. The pulse is weak, slow, fluttering, and often inter- 
mittent, and in the extremities scarcely perceptible. The pupils con- 
tract on the application of light, showing that the retina is not perfectly 
insensible, and as regards the size of the pupil, in the cases of which I 
have kept notes, it was usually contracted when the concussion was 
slight, and dilated when it was very severe. Some authors have occa- 
sionally found one pupil contracted and the other dilated, and in the 
first instance, not dilating in darkness, nor contracting farther when the 
light was suddenly increased. Vomiting is an early symptom, and is 
referred to that well-known sympathy between the brain and stomach, 
of which so many examples could be given ; a sympathy maintained 
through the pneumogastric nerves. If the concussion be severe, and 
the symptoms continue long, there may be the same condition of the 
urinary organs as in compression, the rationale of which condition will 
be explained in the chapter on Compression. 

The above symptoms may be changed into those of the second stage, 
or into those of compression, or they may terminate fatally without 
passing through any further change. 

In the second stage, the operations of mind are not so completely sus- 
pended as in the first, and the insensibility is diminished, although still 
so great, that ordinary impressions produce little effect, and the powers 
of attention and perception are still in a great measure lost ; the func- 
tions of sensation and volition are also in a considerable degree restored. 
In consequence of this alleviation, although the patient lies as in a kind 
of sleep, it is possible to rouse him for an instant. By putting a ques- 
tion to him in a loud, sharp tone of voice, an answer is obtained in a 
monosyllable, and in such a manner, as if his attention were taken up 



CONCUSSION OF THE BRAIN. 215 

about something else, and he instantly relapses into his former state. 
Such questions seem to be more readily answered, if they refer to the 
patient's state. The pupil is usually contracted, and the sensibility of 
the retina is evinced by the patient drawing his head from the light, 
when the eyelids are opened. The functions of the organs of sense, 
though much less acute than naturally, are not entirely suspended ; and 
sensation and power of motion are in a great measure restored, as will 
be shown by his drawing away his limbs when they are pinched. 
Although the patient lies in a comparatively insensible state, and gene- 
rally in the position in which his body happens to be placed, yet there 
are occasional fits of restlessness, and in this respect concussion differs 
from compression, inasmuch as in the latter state, there is uniform and 
permanent insensibility with total loss of the power of motion. The 
circulation and respiration are more vigorous in the second stage than 
in the first ; and in consequence, a natural warmth is diffused over the 
body. The pulse is firmer, fuller, and stronger ; and if the patient be 
so far recovered as to be able to raise himself up, or to make any exer- 
tion, a condition of pulse will be perceptible, which is quite characteristic 
of concussion ; — I refer to its very great acceleration when the patient 
rises up, or makes exertion of any kind. Sometimes when the pulse is 
not more than from seventy to eighty in the recumbent posture, it is so 
greatly accelerated by the patient's rising, as to reach from one hundred 
and twenty to one hundred and thirty in a minute. There is also in 
general, an unusually strong beating of the carotid vessels, especially on 
making exertion ; and when the patient is able to describe his feelings, 
he generally complains of headache. I lately had under my care a 
lady with concussion of the brain, in whose case great throbbing of the 
carotid vessels, and great acceleration of the pulse continued for a very 
considerable time after all other traces of the injury had disappeared. 

The above symptoms may gradually subside, or they may pass into 
those of compression, or into those of the third stage. 

The third stage is one of pure inflammation of the brain, and is indi- 
cated by great pain in the head, increased heat and throbbing of the 
vessels about the head, full and flushed countenance, intolerance of light 
and sound, of light, sometimes even through the eyelids, suffusion of the 
eyes, watchfulness, restlessness, and delirium, together with great quick- 
ness of pulse, heat, and dryness of skin, diminution of secretion, and in 
short, all the usual symptoms of irritative fever. 

These symptoms may yield to remedies, or they may pass into the 
symptoms of compression, and prove fatal in the way of coma. 

Such are the symptoms of concussion in well-marked examples, when 
the disease runs its course; but, as in other injuries, the symptoms vary 
according to the violence of the concussion, so that between slight, tran- 
sient stunning, which wears off in a few minutes, and the state described 
above, there are many intervening shades. Sometimes, the patient 
appears merely to have received a slight stun, and in a few minutes he 
is quite well ; in other instances, the symptoms are more marked and of 
longer duration, yet they wear off without being succeeded by any signs 
of the inflammatory stage ; and in other instances, the disease runs its 
course, and the patient falls a victim to it, death taking place in the 



216 CONCUSSION OF THE BRAIN. 

way of coma. Sometimes concussion and compression exist together, 
and the phenomena of these two states, are so intermingled, that the 
surgeon is occasionally at a loss to determine on which condition chiefly 
the symptoms depend. 

CONSEQUENCES OF CONCUSSION SOMETIMES OBSERVED. 

Some patients recover from even very severe forms of concussion, 
without having in after life any trace whatever of the injury ; but others 
are found to suffer various affections resulting from it, for a considerable 
time after their recovery, or even through their whole life. These con- 
sequences may affect either the mind or the body. The power of con- 
tinuous attention is often lost, or very much diminished ; slight weak- 
ness of intellect, and even complete mental imbecility have sometimes 
been occasioned ; but of all the mental powers, the memory is most fre- 
quently affected, the injury being attended with this peculiarity, that 
all recent events and impressions are forgotten, while those of an earlier 
period are remembered. For example, it has been found that a patient, 
who before concussion, conversed in a language recently acquired, had 
on his recovery entirely forgotten it, but that he was still able to speak 
a language which he had acquired long before. In some cases, the 
recollection has been lost of almost all impressions of a late date, while 
those of early life are distinctly remembered. This affection of the 
memory has been compared to that which takes place in old age, and it 
has been said, that in this respect, patients appear, as far as memory is 
concerned, as if they had suddenly grown old. In some instances, the 
affection of the memory has a different character, and the patient is 
unable to remember the proper word to be used for naming an object, 
or for describing its quality. Desault mentions a curious case of a man, 
who after concussion, could remember only recent events, but after- 
wards lost the recollection of everything recent, and could only remem- 
ber what had occurred in his early life. It is sometimes found that 
some of the organs of the external senses are permanently affected ; 
thus, the use of one ear, or of one eye, may be altogether lost, or the 
sight considerably impaired. In some instances, the sight is affected in 
a peculiar way, so that only part of an object can be seen at one time, 
and the patient must move his head in order to obtain a view of the 
whole object. To such an extent has this been observed in some cases, 
that the patient has been unable to see all the letters of a word at the 
same time. Severe vertigo, or pain of head, on making any exertion, 
and great muscular weakness, are very frequently consequences of con- 
cussion. 

DIFFERENT WAYS IN 'WHICH CONCUSSION PROVES FATAL. 

It would be quite foreign to the object of this work to give any 
detailed account of the experiments made by physiologists to ascertain 
the effect produced on the organs of circulation by injuries on the brain 
and spinal cord ; but the following results of experiments on the ner- 
vous centres, and the conclusion drawn from them, as bearing on the 
interesting subject under consideration, may be here given. 1st. Legal- 
lois, and Dr. Wilson Philip, in their experiments, carefully removed the 



CONCUSSION OF THE BRAIN. 217 

whole of the brain and spinal cord, and when artificial respiration was 
kept up, the action of the heart did not cease for some hours ; from 
which experiments, the conclusion is drawn, that the action of the heart 
is independent of the brain or spinal cord. 2d. In the experiments of 
the same physiologists, it was found that when any sudden and exten- 
sive injury, as a violent concussion, was produced on part of the brain 
or spinal cord, an immediate and great depression, or complete suspen- 
sion of the action of the heart, was the result ; from which it is con- 
cluded that a sudden injury of the nervous centres, such as a violent 
and sudden concussion, suspends the action of the heart, and thus proves 
fatal ; that, in short, death occurs by syncope, or begins at the heart. 
The vital power of the heart seems to be destroyed ; for, when the 
chest is opened immediately after death, it is impossible to excite any 
contraction, and in that respect, as will afterwards be shown, the condi- 
tion of the organ is not the same as in death by coma, where the imme- 
diate cause of death, as will be seen in the chapter on Compression, is 
asphyxia, or suspended action of the lungs. 

3d. From the experiments of Chossart and others, there appears to 
be some variety as to the part of the circulation chiefly affected by 
certain injuries of the nervous centres. Chossart found in some of his 
experiments, that in certain injuries of the brain and spinal cord, the 
circulation in the capillaries appeared to be for some time more affected 
than the action of the heart ; but still it is by failure of the circulation 
that such injuries ultimately prove fatal. It is only by a knowledge of 
the dangers which threaten in different stages that we can be guided to 
rational and scientific principles of treatment. 

When concussion proves fatal in the first stage, it is by failure of the 
action of the heart ; sometimes this failure is instantaneous ; sometimes 
it goes on gradually increasing to a fatal termination ; and sometimes 
there is a very partial reaction, and then a second failure of the organs 
of circulation, which proves fatal. It is evident, therefore, that the 
state of the circulation must, in this stage, be watched with much 
anxiety by the skilful practitioner. 

When concussion has proved fatal by failure of the heart's action, 
the heart is in some cases, particularly in those which have been very 
suddenly fatal, found to be quite empty, a circumstance the cause of 
which, as Dr. Alison remarks, is not easily explained. In other cases 
it is distended ; but the distinguishing peculiarity is, that there is no 
difference in the quantity of blood in its right and left sides : in this 
respect, also, the state of the heart is different in death by asphyxia, as 
will be shown in the chapter on Compression. 

Another way in which concussion proves fatal, is by compression of 
the brain. This may take place soon after the injury, when blood from 
tne vessels of the lacerated portion of brain has had time to accumulate 
in some quantity ; or after reaction has taken place from extravasated 
blood ; or in the third stage from serous effusion, or the formation of 
purulent matter, as results of inflammation. 

APPEARANCES AFTER DEATH. 

The appearances within the head vary according to the length of 
time between the injury and the fatal event. Separation of the dura 



218 CONCUSSION OF THE BRAIN. 

mater from the inner surface of the cranium, when the blow on the 
head was severe, is a very common condition. In cases which almost 
instantly, or very quickly prove fatal, laceration of a portion of the 
brain is often observed ; but it has long been ascertained by the investi- 
gation of surgeons that concussion often proves fatal, and that very 
suddenly, without any perceptible unnatural condition either of the 
cerebral substance, or of the vessels within the head ; in short, without 
any discernible injury of the brain, its vessels, or its membranes. In 
cases rather more advanced, small specks of blood in some parts, or 
laceration of the brain are met with ; and in cases still further advanced, 
besides some of the above appearances, various traces of inflammation 
are observed, such as a turgid condition of the vessels, increased vascu- 
larity in the membranes or brain, or various kinds of inflammatory effu- 
sion, as serous, gelatinous, or purulent, or sometimes of lymph, or 
different combinations of some of the above results of inflammation. 
Surgeons have been anxious to determine in what way concussion sus- 
pends to a fatal extent the function of the brain in those instances, in 
which no derangement of its organization is discernible on dissection. 
Some suppose it may be by the sudden shock disturbing the circulation 
of the brain, but others think it more probable that the structure may 
be injured, although the injury may not be discovered by dissection. 
Sir Benjamin Brodie seems to be of the latter opinion ; he remarks, 
" If the brain is on so minute a scale that our senses are incapable of 
detecting it, it is evident that there may be changes and alterations of 
structure, which our senses are incapable of detecting." Some sur- 
geons, again, seem to think that the fatal suspension of function may 
be caused by condensation of the brain. Mr. Liston says, " When a 
blow is inflicted on the skull, only a slight commotion of the brain is 
induced, the cranial contents are, as it were, slightly jumbled, and a 
temporary and trifling effusion of its functions follows. When, however, 
the stroke is more severe, the brain is separated from its cranial attach- 
ments, both at the point struck, and at the part directly opposite ; it is 
thrown upon itself towards its centre ; its substance is thereby con- 
densed, its diameter in the direction of the impulse diminished, and a 
separation between the brain and cranium is formed at each extremity 
of that diameter. By post-mortem examinations, it has been ascertained 
that condensation of the substance of the brain does exist in cases of 
severe concussion. Such condensation may be sufficient to cause instant 
extinction of life, or the brain may gradually resume its former condi- 
tion, or with only such slight incited action as may be required to 
reunite the dura mater with the inner table of the skull." Such are 
the opinions which have obtained on this subject, but it appears very 
evident that our knowledge of it is still very imperfect. 

Treatment. —There are few points on which greater diversity of 
opinion has prevailed than on the treatment of concussion ; indeed, two 
directly opposite methods have each had their advocates. Some sur- 
geons, from a supposed analogy between insensibility in fainting and 
insensibility in concussion, have advised stimulants and cordials ; while 
others inculcate the necessity of bleeding and other antiphlogistic reme- 
dies. Pott in England, and Boyer in France, insisted on the necessity 



CONCUSSION OF THE BRAIN. 219 

of bleeding ; the latter to an extent unknown in this country. From 
the arrangement of the phenomena of concussion into three stages, from 
the condition on which the symptoms depend, and from what has been 
ascertained regarding the different ways in which it proves fatal, and 
the dangers of each stage, rational and scientific principles of treatment 
have been deduced. The treatment proper for each stage is a subject 
of great practical importance. 

In the First Stage, when the symptoms of depression of the powers 
of life are so urgent that there is danger of death from failure of the 
circulation, it would certainly be extremely injudicious still further to 
depress the system by bleeding ; for this would be almost to take away 
the patient's chance of life : but, on the other hand, it would be hazar- 
dous to administer wine, stimulants, or cordials, as the occurrence of 
phrenitis, the condition on which the third stage depends, would be ren- 
dered more certain, and its severity, if it should occur, be in all proba- 
bility increased. Such means should therefore be employed to restore 
the circulation as are not calculated to have a permanently stimulating 
effect. With this view the patient should be laid in* bed, covered with 
warm blankets, and having heat applied to the surface of the body, 
more especially to the extremities and abdomen. When the circulation 
is restored, the heat should be withdrawn. When the power of swal- 
lowing is regained, if the above means should not have produced the 
desired effect, and the patient be evidently in a very dangerous state, 
the surgeon may venture upon the use of some of the diffusible stimulants, 
such as ammonia. Since ammonia and other diffusible stimulants have 
not any permanent effect on the circulation, there is not the same 
objection to their use as to that of brandy, wine, or any such powerful 
stimulants. The state of depression is generally but temporary, and 
the reaction usually proportioned to the depression ; hence the danger 
of giving any powerful stimulant. If there should happen to be lacera- 
tion of the brain, which, as has been already stated, is a condition often 
existing in concussion, then the period of depression of circulation tends 
to diminish the danger of internal hemorrhage ; and this furnishes an 
additional argument in favour of the practice of avoiding stimulants : 
whereas, if the circulation be artificially excited, there is greater danger 
of compression from internal hemorrhage, and of phrenitis ; and it has 
been already mentioned that these are two of the ways in which concus- 
sion proves fatal. 

In the Second Stage, the object to be aimed at is, to moderate the 
reaction, and thus to prevent, if possible, the occurrence of the symp- 
toms of the third stage. The patient should be placed in a cool, quiet, 
dark room, and every external source of excitement avoided ; the 
shoulders should be a little raised; the head shaved, and cold applica- 
tions applied to it ; the bowels should be freely purged, and the diet of 
the most unstimulating kind. If there be any evidence of increased 
vascular action, it -may be advisable to bleed from the arm ; but on this 
point the surgeon must be guided entirely by the state of the pulse, and 
not by the insensibility, which cannot be removed by bleeding. After 
the proper restoration of the circulation, if there be evidence of increased 
vascular action, a moderate bleeding may prevent phrenitis ; and, if 
there be laceration, it may tend to arrest extravasation of blood on the 



220 COMPRESSION OF THE BRAIN. 

brain. When recourse is had to bleeding in this stage, it is chiefly as 
a precaution. 

In the Third Stage, the treatment is the same as in ordinary cases of 
phrenitis, namely, depletion both general and local ; the efficient appli- 
cation of cold to the head by means of cloths out of evaporating lotions, 
or of water rendered very cold by ice, or of ice itself and water in a 
bladder ; smart purging of the bowels, with low diet, and attention to 
all necessary precautions for avoiding light, noise, and everything which 
could prove a cau'se of excitement or irritation. Care, however, must 
be taken that bleeding be not carried too far. The following reasons 
suggest the necessity for caution. 

1. If there be laceration of the brain, the amount of inflammation 
necessary for obtaining reunion may be prevented. Sir Astley Cooper 
records a case which occurred in the practice of another surgeon, where 
depletion was carried too far, and on dissection there was found lacera- 
tion, without any attempt at reunion. 

2. Phrenitis is an inflammatory disease, in which it is well known 
that patients do not bear depletion to the same extent as in some other 
inflammatory attacks. 

3. Repeated copious bloodletting produces of itself confusion of mind, 
pain of head, a hardness and jerking condition of pulse, giddiness, and 
other symptoms, which an inexperienced observer may mistake for the 
symptoms of the injury. 

When the powers of life in this stage seem to be failing, recourse may 
be had to stimulants ; and it is surprising how patients sometimes rally 
under them in instances where the symptoms are very unpromising, and 
death seems very near. 

Throughout all the stages the state of the bladder must be carefully 
attended to, and the catheter used, if necessary. 

COMPRESSION OF THE BRAIN, OR COMA. 

Symptoms. — In sanguineous apoplexy we have a good illustration of 
the symptoms of compression of the brain. In well-marked cases there 
is complete suspension of consciousness and of all mental operations. 
From the brain being incapable of receiving impressions from the 
nerves, there is suspension of the functions of the external senses, 
and of common sensation ; and from its being unable to transmit the 
influence of the will through the nerves to the muscles, there is loss 
of voluntary motion. The muscles are relaxed, and the body remains 
in any position in which it may be placed. Both in compression and 
in concussion, sensation and voluntary motion are suspended ; the cha- 
racteristic difference is, that in the former the suspension is constant 
and uniform while the compression continues ; in the latter there are, 
even during the continuance of the concussion, occasional fits of rest- 
lessness, and the symptoms have a tendency to wear off. 

The retina is perfectly insensible ; if the eyelids be opened and a 
candle be placed near, no perception of light is evidenced ; the iris is 
motionless, and the pupil dilated. This is the condition of iris gene- 
rally found, and, therefore, regarded as a symptom of compression, 



COMPRESSION OF THE BRAIN. 221 

though sometimes the pupils have been found at first contracted and 
fixed, and afterwards dilated and fixed. 

The respiration is slow, difficult, and stertorous. The relaxation of 
the velum pendulum palati, and of the muscles of the larynx and pha- 
rynx, prevents the free passage of the air, and gives rise to the noise in 
breathing called stertor. In very bad cases the air puffs out the cheeks 
and lips, and elevates the latter in passing out : this is always viewed 
as an unfavourable symptom. In consequence of the insensibility, the 
uneasy sensation in the chest caused by the presence of venous blood in 
the lungs, which under ordinary circumstances excites respiration, is 
not felt ; and in addition to this, the muscles of respiration are paralysed. 
It is this condition of the respiratory apparatus which is the immediate 
cause of death ; in other words, death is caused by asphyxia ; and, 
therefore, the condition of respiration is watched by the surgeon with 
the utmost anxiety. 

The pulse is for the most part slow, full, and labouring. It has 
already been stated that, although the action of the heart is independent 
of the brain, inasmuch as the whole of the brain of 'an animal can be 
removed, and if the respiration be kept up, the action of the heart will 
continue for some hours, yet it is disturbed by a sudden injury of the 
nervous system ; — in concussion for example, the heart's action is dimi- 
nished to a very great degree in the manner already described ; in com- 
pression, however, the pulse is affected in a different way. In concus- 
sion, it is weak, small, and fluttering, whereas in compression it is slow, 
full, and labouring. The action of the heart is diminished, weakened, 
and sometimes entirely suspended by concussion, as by a sudden injury 
of the nervous system ; whereas in compression it does not seem to be 
at all affected directly, but to become impeded and interrupted from the 
obstruction of circulation through the lungs, caused by the tendency to 
asphyxia. In the one case the effect is produced directly on the action 
of the heart, in the other directly on the action of the lungs, thereby 
rendering it more than ordinarily difficult for the heart to perform its 
function. Experiments of sawing out a portion of the cranium, and 
applying pressure to the brain, have been performed on the lower ani- 
mals, to ascertain the effect on the pulse; and the result observed has 
been, that the pulse becomes slower and labouring when severe pressure 
is applied, and rises when the pressure is removed. The same effect is 
observed in injuries of the human body ; when the brain is severely 
compressed by a depressed portion of bone, the pulse becomes slow, and 
it is observed to rise, and often very suddenly, when the pressure is 
removed. This effect, as has been already stated, is believed to be occa- 
sioned by the condition of the lungs. Some cases are recorded in which 
the pulse became exceedingly slow. Dr. John Thomson mentions a case 
of compression from fracture with depression, where it fell to thirty-six 
in a minute ; and I had an opportunity of watching a case where it 
became as low as thirty-two. Though compression is usually charac- 
terized by the condition of pulse here described, some instances have 
occurred where the other symptoms have been well marked without any 
perceptible change of circulation. Intermission of pulse, though observed 
in concussion, is not met with in compression. 



222 COMPRESSION OF THE BRAIN. 

The symptoms affecting the alimentary canal are, that there is loss of 
the power of swallowing from paralysis of the muscles of deglutition ; 
the bowels are constipated, and from the sphincter ani being paralysed, 
the feces are passed involuntarily. Vomiting, which is usual in con- 
cussion, is very rare indeed in compression, it is only present under one 
or other of the following circumstances, namely, at the commencement 
of slightly marked cases, where it is probably owing more to concus- 
sion than compression ; and in severe cases of compression on the sud- 
den removal of the cause of pressure, as on the removal of the depressed 
portion of the bone. Vomiting indicates a greater degree of sensibility 
and irritability than are generally met with in compression. 

The bladder being paralysed cannot pass off the urine. Unless death 
soon follows, this retention of urine, as pointed out by Desault, is suc- 
ceeded occasionally by a dribbling or sort of incontinence of urine ; 
for the bladder becomes so enormously distended that the urine forces 
the sphincter to such an extent as to allow a small quantity to dribble 
off, yet not sufficient to relieve the distension, or to obviate the neces- 
sity of the introduction of the catheter. 

Convulsive twitches are sometimes met w T ith in individuals suffering 
under compression of the brain ; but, according to Bichat and Brodie, 
they are not indications of compression, but are believed to be more 
frequently connected with laceration or wound of the brain than with 
any other condition. 

Manner in which Compression proves Fatal. — In describing the symp- 
toms of compression it has been already stated that it proves fatal by 
failure of respiration, or in other words by asphyxia. All sensibility 
being destroyed, the sensation caused by the presence of venous blood 
in the lungs, which is the stimulus to respiration, is not felt ; the muscles 
of respiration are also paralysed. After death, the veins leading to the 
right side of the heart, the right side of the heart itself, and the trunk 
and branches of the pulmonary artery, are found greatly distended with 
venous blood, and the left side of the heart is empty. These condi- 
tions depend on the obstacle to the transmission of blood through the 
lungs caused by the failure of respiration. This is a different state of 
parts from what was described in cases where concussion proves fatal by 
failure of the heart's action. 

There is another circumstance in which the state of the heart differs 
very much in death from compression, and death from concussion. 

In concussion, the heart's action seems to be completely destroyed, 
so that it cannot be excited to contract, although the chest of an animal 
be opened immediately after death, the irritability of the organ being 
destroyed ; whereas in compression, if the heart, whose action in this 
form of death by asphyxia continues for a few seconds even after the 
last breath, be exposed immediately after death, it may be excited to 
contract, either by allowing seme of the contents of the right side to 
escape, or by irritating it ; thus showing that its irritability is not 
destroyed, as it is in death by concussion beginning at the heart. In 
compression, the action of the heart ceases at last, the right side being 
unable to contract from over-distension, and the left from the want of 
its ordinary stimulus, the blood. 



INJURIES OF THE HEAD. 223 

Causes and Treatment. — The causes of compression from injury are 
three : fracture with depression, extravasation of blood, and the formation 
of matter. For a description of the symptoms, diagnosis, and treatment of 
these three different conditions, I beg to refer to the sections on fracture 
with depression, and fracture of the internal table. I think it necessary 
here only to add, that extravasation may take place in any of the five 
following situations : first, between the cranium and dura mater ; second, 
under the dura mater into the cavity of the tunica arachnoidea ; third, 
between the tunica arachnoidea and pia mater ; fourth, between the pia 
mater and the brain ; and fifth, into the substance of the brain itself. 
There does not seem to be any difference in the symptoms, whatever be 
the situation of the blood ; and it is only when in the first-mentioned 
situation that relief can be given by trephining, because, in addition to 
other reasons, it is then only that its situation is circumscribed. I am 
aware of some extraordinary cases, where relief has been afforded by 
puncturing the dura mater ; but notwithstanding these exceptions, the 
above, as a general rule, will be found to be correct. When suppura- 
tion takes place, it may be in any of the above-named situations. Ac- 
cording to Pott, when the matter is between the cranium and dura 
mater, its existence is indicated by a puffy tumour of the scalp, and a 
separation of the pericranium from the outer table of the cranium. 
This condition does occasionally present itself, but it certainly is not 
an invariable symptom, as cases have occurred in which this condition 
was not present, and yet on dissection matter was found between the 
cranium and dura mater. That such is the case, Bichat says is proved 
by daily experience at the Hotel Dieu. 

CONDITIONS WHICH JUSTIFY THE OPERATION OP TREPHINING. 

From what has been stated regarding injuries of the head, it will 
appear that operative interference is thought to be justifiable under the 
following circumstances : — 

1. In simple fracture with depression, provided the symptoms persist 
after the use of depletion, purging, and the other alleviating remedies. 

2. In compound fracture with depression without symptoms of com- 
pression. 

3. In punctured fracture without symptoms of compression. 

4. When the symptoms are very urgent, and the surgeon thinks he 
has good reason to believe, that they are caused by blood or purulent 
matter underneath the cranium and above the dura mater, or by fracture 
with depression of the inner table. 

In each of the first three conditions, it is considered necessary to 
adopt proceedings for raising the depressed portion of bone to its proper 
level. If, on exposing the fracture, it is found that this cannot be done 
by means of the elevator, which is often the case, in consequence of the 
fractured portions being so related that it is impossible to insinuate the 
extremity of the elevator underneath the depressed portion, then it is 
advisable to remove a small portion of the cranium by means of the 
trephine, for the purpose of allowing the introduction of the elevator, 
by which the depressed part is to be raised. The instrument used by 
the ancients was the trepan, and the operation was called trepanning ; 



224 INJURIES OF THE HEAD. 

the instrument now used is called the trephine, and the operation, 
trephining. 

Such are the views now entertained in these later and better times of 
surgery, as to the conditions which justify and require the operation of 
trephining. We find, however, from the history of surgery, that a very 
different doctrine prevailed in former days : — that so great was the rage 
for trepanning among the ancients, that the very slightest fissure, or 
even the mere suspicion of one, was considered to be sufficient warrant 
for the operation'; — that they trepanned in all fractures, whether 
attended by depression or not, whether accompanied by symptoms of 
compression or otherwise ; — that they operated when bad symptoms 
were present, to remove them, — when absent, to prevent them ; so that 
they elevated every depression, trepanned every fracture, and, in ope- 
rating on a longitudinal or a radiated fracture, they trepanned along 
the whole of its course, so as to saw it out ; and did not allow a single 
fissure of it, or rima, as they called it, to escape. In operating for the 
removal of a coagulum, they made as many openings as would uncover, 
if possible, the whole of it ; and, says Ravaton, " I have seen surgeons 
so infatuated, so desperately bent on discovering abscess on the dura 
mater, that, after applying six crowns of the trepan, they would, and I 
verily believe have, pulled away all the remaining bones of the cranium, 
had not their patients been delivered by death from such operations." 
All this was done, they said, to remove danger. It is almost incredi- 
ble to what a disgraceful extent this passion for trepanning was allowed 
to outrage common sense ; and it is difficult to imagine how they could 
believe a fracture to be so dangerous, and their operations so safe. To 
show the extent to which trepanning was carried, Mr. John Bell gives 
the following quotation : — " Godifredus, Chief Surgeon to the States of 
Holland, mentions with particular exultation the performance of this 
operation by his friend, who trepanned the cranium of the Count of 
Nassau twenty-seven times, and that the fact might be established on 
indisputable authority, he made the said Count of Nassau, after he was 
recovered, write the following curious certificate, on the 12th day of 
August, 1664 : — ' I, the underwritten, Philip Count Nassau, hereby 
declare and testify, that Mr. Henry Chadborn did trepan me in the 
skull twenty-seven times, and after that did cure me well and soundly.' ' 
These practices, and the numerous inventions of instruments for cutting 
the skull, are sad monuments of the surgery of past ages. In later 
times the Royal Academy of Surgery in France revived and defended 
the doctrine that all fractures of the cranium ought to be trephined. It 
does seem surprising that this body of men, convened for the purpose of 
ascertaining the principles which ought to regulate the practice of our 
science, and to whom surgery is in other respects so greatly indebted, 
should, by giving the sanction of their high authority to so dangerous a 
doctrine, have led the younger members of our profession to adopt very 
dangerous rules of practice. The unfortunate results of the operation 
were so numerous, that the celebrated Desault, one of the greatest orna- 
ments of surgery in France, forming his opinion from what he saw at 
the H6tel Dieu, strongly condemned the practice, and, in the latter part 
of his life, entirely discarded it. The doctrine of the French Academy 



FRACTURES OF THE FACE. 225 

met with a most powerful advocate in this country, in the late Mr. Pott, 
who, with all the great talent and decision for which he was so eminently 
distinguished, maintained the doctrine of trephining in almost every 
fracture, to prevent as well as to remove bad symptoms. He states 
that fracture of the skull in many cases is not attended with any symp- 
toms actually demanding this operation at the moment ; but that 
although there may be no symptoms denoting affection of the mem- 
branes, or of the brain itself, yet inflammation of those parts will, in 
consequence of the fracture, come on at a more or less remote period, 
and that, therefore, recourse ought to be had to the operation. Mr. 
Pott, in speaking of the doctrine of trephining, says, " I am as much 
convinced of this as of any fact which repeated experience may have 
taught me," and throughout his writings on that subject, he gives his 
opinion with so much decision, supporting it by cases and arguments, 
that his views cannot fail to have produced a very decided impression. 
Notwithstanding, however, all the eloquence and talent with which he 
supported his views, the doctrine he taught is now abandoned ; and in 
these later and milder times of surgery, operative procedure is considered 
justifiable only under the circumstances mentioned at the commencement 
of this section. 



[FRACTURES OF THE FACE. 
FRACTURE OF THE BONES OF THE NOSE. 

Causes. — Owing to the prominence of the nose, the nasal bones are 
much exposed to fracture. It generally requires considerable force to 
break the arch formed by the articulation of the nasal with the superior 
maxillary bones. Direct blows, or severe falls, are the most common 
causes of the accident. 

Symptoms. — In many cases the contusion of the neighbouring soft 
parts is so great as to produce great swelling, and diagnosis is not 
always easy immediately after the fracture ; but even if crepitus cannot 
be distinguished, the mobility of the parts will often be characteristic. 
Bleeding from the nose, and injury of the brain, may also be present. 
The injury of brain is apt to be from concussion, rather than from com- 
pression. If the inflammation be great, there may be exfoliation of the 
bones of the nose, or the inflammation may extend to the dura mater, 
which will produce deep-seated pain in the neighbourhood. 

Nature of the Displacement. — If the fracture is simple, the displace- 
ment would be slight, and but little deformity would result ; but if the 
bones are crushed, the bridge of the nose will be destroyed. 

Treatment. — This will depend upon the amount of inflammation and 
the displacement. Should the fracture be simple, antiphlogistic mea- 
sures may be all that is necessary ; but if the bones are crushed and 
pressed in, they must be adjusted by a large probe, or a female catheter. 
Compresses applied on each side of the nose, may be of use in retaining 
the fragments in apposition. Stopping up the nostrils with plugs of 
lint, or any other material, will be found of no service ; on the contrary, 
they will be more likely to do harm by increasing the inflammation. 



226 FRACTURES OF THE FACE. 



FRACTURE OF THE MALAR BONE. 

Causes. — This bone is rarely fractured, unless from great violence, 
which will also produce great contusion of the soft parts. It is easily 
recognised, unless the swelling be very great. 

Treatment. — The swelling and inflammation are to be removed by 
appropriate remedies. The jaw must be kept perfectly quiet, which 
can be best effected by Barton's bandage for fracture of the lower jaw. 
The patient should not speak nor masticate. Should fragments of 
broken bone be driven into the temporal muscle, which would inter- 
fere with chewing, it might be necessary to cut down upon the fracture 
and elevate the pieces of bones. 

When small portions are split off from the edges of the malar bone, they 
are frequently reduced in size, by absorption, previously to their uniting. 

FRACTURE OF THE UPPER JAW. 

The superior maxillary bone is sometimes fractured at its nasal pro- 
cess, in connexion with fractures of the nose. Its alveolar processes are 
also liable to fracture, though the injury is not a serious one, unless it 
is the result of a gun-shot wound, involving the antrum Highmorianum. 

Fragments of alveolar processes will sometimes unite if properly pressed 
to their place, and the jaw be kept at rest. 

Fracture involving the antrum, would be attended with great swelling 
and pain, and the inflammatory symptoms would require antiphlogistic 
remedies. 

FRACTURE OF THE LOWER JAW. 

This results from direct violence, which must be very considerable to pro- 
duce a fracture in a bone which is so strong and at the same time so mobile. 
The seat of fracture may be in the body, rami, or processes, and it 
may happen that the fracture will occur at the symphysis, although this 
is rare even in children. The direction of the fracture may be either 
vertical, horizontal, or oblique. A portion of the alveolar process may 
be broken, without any serious inconvenience. The most frequent 
situation of the fracture is between the symphysis and the insertion 
of the masseter muscle. 

Symptoms. — There is no difficulty in the diagnosis. The history of 
the case, the pain upon moving the jaw, the unevenness of the base, the 

irregularity of the teeth, and the 
Fi S- 56 - crepitus, are sufficient. The larger 

fragment, to which the chin is at- 
tached, will be found to be drawn 
downwards. If the fracture is 
double, the displacement will be 
greater, and the middle portion, or 
chin, will be drawn downwards. 
The gums are frequently lacerated, 
and bleed. 

When fracture occurs in the neck 
of the condyloid process, it is not so 
easily recognised. In the accompanying wood-cut, taken from Fergus- 




FRACTURES OF THE FACE. 



227 



son, there is represented a fracture of both condyles. It is to be dis- 
tinguished by the pain near the ear, by crepitation, and by the condyle 
being drawn forward by the action of the pterygoideus externus muscle. 

Treatment. — The fragments are generally coaptated without difficulty 
in single fractures ; but in double fractures, more care is required. In 
either instance, the great object is to keep the lower jaw firmly pressed 
up against the upper, which acts as a splint. A simple dressing con- 
sists of a moistened piece of pasteboard, moulded to fit the jaw, and 
secured by a four-tailed bandage, which has a slit in its middle, into 
which the chin is placed. The two 
upper tails are to be tied behind the Fig. * 57 - 

neck, and the two lower ones tied upon 
the crown of the head. In young 
persons, and in double fractures, it 
will sometimes be found convenient to 
fasten the teeth together with strong 
silk, or fine silver wire. In many cases 
it will be sufficient to place a large, 
thick compress under the chin, and 
apply Barton's bandage. It consists 
of a roller, five yards long and two 
inches wide. " Place the initial extre- 
mity of the roller upon the occiput, 
just below its protuberance, and con- 
duct the cylinder obliquely over the 
centre of the left parietal bone to the 
top of the head ; thence descend across 
the right temple and the zygomatic 
arch, and pass beneath the chin to the 
left side of the face ; mount over the 
left zygoma and temple to the summit 

of the cranium, and regain the starting point at the occiput by tra- 
versing obliquely the right parietal bone; 
next wind around the base of the lower jaw, Fl S- 58 - 

on the left side, to the chin, and thence return 
to the occiput along the right of the maxilla ; 
repeat the same course, step by step, until 
the roller is spent, and then confine its ter- 
minal end." 

If the parts are kept perfectly quiet, union 
takes place readily in four or five weeks, 
there being abundant vascular supply ; and 
usually no deformity results. The patient 
is to be nourished by fluids, and there is 
usually room enough for soups and gruels to 
find their way into the mouth through the 
interstices of the teeth. Some surgeons 
recommend the introduction of thin pieces of cork on each side between 
the molar teeth, leaving an aperture between the incisors sufficient for 
the introduction of food or medicine by a small spoon. — Ed.] 

1 Sargent's Minor Surgery. 





228 



CHAPTER VII. 

DISLOCATIONS. 



By a dislocation is meant the removal of the articulatory surface of 
a bone from the part with which it is naturally in contact. For rightly 
understanding and successfully treating dislocations, it is absolutely 
necessary to have a thorough acquaintance with the form and relations 
of the bones at their extremities, the position of the ligaments, and the 
attachments and actions of the surrounding muscles. As to the impor- 
tance of anatomical knowledge in order to understand these injuries, 
two great surgical authorities have thus expressed themselves : — " There 
is necessary," says Sir Astley Cooper, "a considerable share of anato- 
mical knowledge, to detect the nature of these accidents, as well as to 
suggest the best means of reduction, and it is much to be regretted that 
our students neglect to inform themselves sufficiently of the structure of 
the joints. They often dissect the muscles of a limb with great neat- 
ness and minuteness, and then throw it away without a proper exami- 
nation of the ligaments, the knowledge of which, in a surgical point of 
view, is of infinitely greater importance ; and from hence arise the 
numerous errors of which they are guilty, when they embark in the 
practice of their profession ; for injuries of the hip, shoulder, and other 
joints, are scarcely to be detected but by those who possess accurate 
anatomical knowledge." Mr. Percival Pott, in his works, observes, 
" In both fractures and dislocations a perfect knowledge of the disposi- 
tion, force, attachments, and uses of the muscles, at least those of the 
limbs, is absolutely and indispensably necessary ; and if the young stu- 
dents would be careful in attending to the plain and obvious parts of 
anatomy ; if they would with their own hands dissect the muscles, ten- 
dons, blood-vessels, and nerves ; if they would examine minutely the 
structure, dispositions, and connexions of all the parts which form the 
various joints, with their ligaments, and attend to the effects which the 
actions of the muscles and tendons connected therewith must necessarily 
have on them, they would have much more precise and adequate ideas 
of luxations than many of them have ; they would have ideas of their 
own, not taken upon trust from writers, who for ages have done little 
more than copy each other ; and they would act with much more satis- 
faction to themselves." 

There are few bones in the body that may not be displaced by the 
application of enormous force ; but there are some, — as, for example, 
the vertebrae, and the bones of the pelvis, carpus, and tarsus, so firmly 
joined together, that although by extreme violence the ligaments and 



DISLOCATIONS IN GENERAL. 229 

other structures by which they are so powerfully tied together and 
maintained in their natural relations, may be injured to such an extent 
as to admit of the bones being displaced, yet the application of extreme 
force in such cases produces other effects of so dangerous and destructive 
a character that the separation of the bones is a matter of inferior im- 
portance. The articulations which are principally subject to dislocation 
are the ginglymoid, and the orbicular ; more especially the latter. The 
reason of this difference will at once be perceived on observing in the 
ginglymoid joints the mutual correspondence of the eminences and de- 
pressions of the bones, the number, strength, and firmness of their liga- 
ments, and the configuration of the parts, which, like a hinge, admits of 
motion only backwards and forwards in a single plane ; whereas, in the 
orbicular joints, the very shape of the bones, the comparatively loose 
condition of the ligaments, and the formation of the joints so as to allow 
very extensive and diversified movement, all contribute to increase the 
liability to dislocation. 

Dislocations may be complete or incomplete, accidental or spontaneous : 
that is, the articular surfaces may be either completely, or only par- 
tially separated from each other ; they may be caused by external 
violence, when they are called accidental, or, in consequence of disease 
in a joint, the bones and ordinary ligamentous restraints may be so 
destroyed, that the common actions of the muscles produce the displace- 
ment of the bones without any external violence. This spontaneous 
dislocation is met with in the hip and in the knee ; but, as in this part 
of the work we are considering the separation of the ends of bones 
caused by external violence, we shall defer any further reference to 
spontaneous dislocation until we come to describe the phenomena con- 
nected with the diseases of joints. An incomplete dislocation is of 
comparatively very rare occurrence in the orbicular joints, but in the 
ginglymoid it is frequent, from the very great breadth of articulating 
surfaces. 

Another arrangement, which in a practical point of view is of great 
importance, divides dislocations into two classes, simple and compound. 
A dislocation is said to be simple, when the articulation is not laid open, 
and compound, when the head of a bone is not only dislodged from its 
articular cavity, but forced through the integuments, or complicated 
with a communicating wound of the soft parts extending into the joint. 

In treating of simple dislocations we shall consider — 

I. The causes of dislocation. 

II. The symptoms. 

III. The general indications of treatment. 

IV. The consequences of an unreduced dislocation. 

I. The Causes of dislocation may be arranged into predisposing, and 
exciting. To the former belong shallowness in the form of a joint; 
great looseness of -its ligaments; great latitude of motion ; weakness of 
surrounding muscles, whether from emaciation and debility, or from 
paralysis ; weakness and relaxation of the soft parts from previous dis- 
locations; unusual distension of a joint from an inordinate accumulation 
of synovia ; and destruction of the ordinary organs of relation from dis- 



230 DISLOCATIONS IN GENERAL. 

ease. The exciting causes are external violence and excessive mus- 
cular exertion. Of these many examples might be given. External vio- 
lence may be applied directly or indirectly ; for an example of each we 
may mention two ways in which the shoulder is dislocated. Dislocation 
downwards of the shoulder is sometimes produced by violence applied 
to the upper part of the humerus, by which the head of the bone is di- 
rectly forced down into the axilla ; and sometimes by the indirect ap- 
plication of violence, as when by a fall, or by other means, the elbow is 
forcibly raised upwards, and the head of the bone is thus driven against 
the under part of the capsular ligament. The displacement of the pa- 
tella will furnish an illustration of the manner in which excessive mus- 
cular action may give rise to dislocation. The natural position of the 
patella is such that it prevents the fibres of the rectus muscle from going 
in a straight direction from their origin at the pelvis to the anterior 
tuberosity of the tibia, into which they may be considered as being in- 
serted through the medium of the fibrous covering on the front of the 
patella and the ligamentum patellae. The bone, preventing these fibres 
from going in a straight direction from the pelvis to the leg, causes 
them to describe an arch, the convexity of which is inwards. When 
the muscle is violently called into action, it will have a tendency to 
draw the patella outwards, in its endeavour to pass straight to the tibia, 
and thus a dislocation outwards is often produced. If the muscle be 
violently called into action while the knee is bent inwards, a dislocation 
will be still more likely to ensue. At the temporo-maxillary articula- 
tion, a dislocation is often caused by muscular contraction, as will be 
afterwards explained. 

II. Symptoms. — One of the most constant and characteristic symp- 
toms of dislocation, and one which seems to distinguish this injury from 
fracture, is the fixed condition of the limb. In some cases there is abso- 
lute immobility of the limb, so that it can neither be moved by the volun- 
tary efforts of the patient, nor even by the surgeon. This complete immo- 
bility is usually found in joints which move only in a single plane ; for 
example, it is particularly observed in dislocation backwards of the elbow. 
In other instances, although the muscles about a joint cannot excite 
motion, the limb may be very slightly moved in one particular direc- 
tion ; for instance, in some cases of dislocation downwards of the hume- 
rus into the axilla, the arm can be raised upwards to a certain extent 
by the surgeon, while it may be perfectly immovable in every other di- 
rection. But slight mobility in one direction, though occasionally ob- 
served, is not found in many instances, and therefore a fixed condition 
of a limb may be considered as a general symptom of dislocation. 
Sometimes the mobility is not entirely lost for two or three hours, or 
even longer, after the accident. This is believed to arise chiefly from 
the muscles requiring some time to shorten and accommodate them- 
selves to their altered condition, and partly from the irritation and in- 
flammation caused by the unnatural position of the bone. The patient 
feels more pain and tenderness in consequence of the irritation and in- 
flammation, and, therefore, naturally offers greater resistance to any 
moving of the limb. A second symptom particularly deserving notice, 
is the unnatural direction of the axis of the bone. This is a striking 



DISLOCATIONS IN GENERAL. 231 

symptom, and to be especially observed. As a good example we may 
mention dislocation downwards of the shoulder, in which the axis of the 
humerus is directed into the axilla, instead of being in its natural posi- 
tion. This symptom presents itself immediately on the occurrence of 
dislocation, and remains until reduction is effected. A third, and very 
frequent symptom, is some alteration in the length of the limb. The 
dislocated extremity is in most instances shortened, but is sometimes 
lengthened ; as, in dislocation downwards of the shoulder, and disloca- 
tion downwards of the hip. In the under extremity, the presence or 
absence of this lengthening is a good diagnostic symptom between dislo- 
cation and fracture ; for it is found in dislocation downwards of the hip- 
joint, but never occurs in any fracture of the under extremity. A 
fourth symptom is some unnatural appearance about the joint, by which 
its shape is changed. These alterations of form differ, of course, in 
different dislocations. A fifth symptom is slight, soft crepitation, or a 
simulation of crepitus. This is a symptom of which the practitioner 
ought to be well aware, lest he be deceived by it, and led to mistake a 
dislocation for a fracture. The crepitation in dislocation is of a soft, 
crackling, oozy, sloppy character, easily distinguished from the hard 
grating crepitus of fracture, and is supposed to arise from the escape 
of synovia, and serous effusion, into the surrounding cellular tissue. 
Sometimes, however, there is in dislocation a hard crepitus, in conse- 
quence of small osseous scales being torn off from the bone, where the 
muscles are inserted into it. In addition to the above symptoms there 
are sometimes great swelling, pain about the joint, great pain at the ex- 
tremities of the nerves, the trunks of which may be pressed by the head 
of the bone. There may also be numbness, or even paralysis of the 
limb, if the pressure on the nerves be to a great extent, and oedema, if 
the pressure be on the vessels returning blood from the extremity. 

III. Treatment. — In the treatment of dislocations the indications 
are three : — 

1. To restore the bone to its natural situation : — this is termed re- 
duction. 

2. To preserve the parts reduced in their natural position, until the 
lacerated ligaments have had time to unite. 

3. To prevent unfavourable symptoms, or, if they have already oc- 
curred, to remove them. 

The first and paramount indication is reduction, which should be im- 
mediately attempted ; for it becomes increasingly difficult with the 
length of time from the occurrence of the dislocation, and is, after a long 
interval, altogether impracticable. It is universally agreed that the 
chief impediment to the reduction of a recent dislocation is muscular 
action. Some muscles, having their extremities brought nearer to each 
other than is natural, become permanently contracted, and accommodate 
themselves to their new condition. The proofs of this are found in the 
facility with whioh reduction is accomplished, when the accident has 
happened in a limb affected with paralysis, or in a weak, relaxed, and 
emaciated person ; or when the muscles are incapable of making much 
resistance through any great temporary weakness, or extreme prostration, 
or collapse, or through the patient being faint or debilitated by bleeding, 



232 DISLOCATIONS IN GENERAL. 

nausea, or other means. Additional proof that muscular action is the 
chief impediment to reduction, is given in the fact, that if the mind of 
the patient be diverted from the accident, and be directed to other sub- 
jects, while attempts are being made to accomplish reduction, the surgeon's 
design is more easily effected, the muscles are then taken, as it were, by- 
surprise ; but if the attempt be made while the mind of the patient is on 
the watch, the muscles will resist with their utmost power, and great 
difficulty will be experienced. These facts furnished useful hints in 
practice, and suggested the property of various means employed in diffi- 
cult cases to increase the efficiency of the methods adopted for accom- 
plishing reduction. 

The condition of the parts about the joint differs at different periods, 
if it be long before reduction is attempted. Immediately after the acci- 
dent, the muscles are relaxed from the depression of the system, prin- 
cipally caused by the shock of the injury, and this condition is very 
favourable for reduction ; soon, however, they become spasmodically 
rigid, and ultimately, if reduction be not accomplished, they become 
completely adapted to their altered condition; the laceration of the 
ligaments is gradually filled up by the effusion of adhesive lymph, and 
if the ligament be a capsular one, with a rent, through which the head 
of the bone has escaped, the diminished size of this opening from the 
effusion of lymph will, in time, present a further obstacle to the return 
of the bone into its natural situation. To overcome the contraction of 
the muscles, extension and counter-extension are employed. It must 
be manifest that simply drawing or extending the limb would not have 
much effect on the muscles around the joint, but that to make the whole 
force bear upon them, both extension and counter-extension are to be 
used. For instance, when you have to reduce a dislocation of the shoul- 
der, you first fix the scapula ; in other words, you use counter-extension. 
You next apply the extending force to the arm ; but this, without coun- 
ter-extension at the same time, would answer no useful purpose, for the 
extending force, instead of acting on the muscles around the joint, 
would act on the whole body ; so that counter-extension, that is, the 
fixing of the body, is obviously just as necessary as the application of 
force to the bone which has been dislocated. 

By British surgeons, extension and counter-extension are applied as 
near as possible to the dislocated joint : for example, in dislocation of 
the hip, the counter-extension is applied to the pelvis, and the extension 
to the thigh ; because the whole force is thus directed against the mus- 
cles, which oppose the reduction. In France, this practice is objected 
to, on the ground that the muscles which have to be stretched, must, in 
extension, be irritated by the pressure, and excited to contract, thereby 
offering increased resistance to the accomplishment of reduction. The 
French apply extension at a distance from the dislocation ; for example, 
in reducing a dislocation of the hip-joint, the extension is applied to the 
leg, not, as in this country, to the thigh. 

A point of considerable importance is, the best method of using 
extension ; whether short and violent efforts should be made, or whether 
the force should be continued even and uninterrupted. On this subject 
Professor Samuel Cooper remarks : — " The invariable maxim in reducing 



DISLOCATIONS IN GENERAL. 233 

dislocation is, not to make the extension with sudden and considerable 
violence, but gradually, and, at the same time, steadily and unremit- 
tingly. It is safer to tire out the opposition of the muscles by gradually- 
increased uninterrupted force, than by resorting to short efforts of 
great violence. In this latter practice you run the risk of producing 
considerable mischief ; you may rupture arteries and veins ; you may 
contuse and injure important nerves ; or you may lacerate the soft parts. 
But with all these objections, you will gain nothing, for you would have 
less chance of getting the bone into its place, than by a milder and 
more judicious plan. The principle, I repeat, then, is to make the 
extension slowly and gradually, and at the same time unremittingly ; 
for no muscles, however powerful they may be, can resist force thus 
employed against them, beyond a certain time, and they must, eventually, 
become tired out." The manner in which extension and counter-exten- 
sion are employed, varies in different dislocations, as will afterwards be 
observed, when the dislocations are described. 

In employing extension, the greatest care is necessary so to apply it 
that the injury to the soft parts may be as little as possible. With 
this object, various means are taken to avoid bruising or excoriating 
the part to which the force is applied ; a few turns of a roller, wetted, 
that it may be less apt to slip, or a portion of soft wash-leather, or a 
damp towel, may for this purpose be put round the part to which the 
extension is to be applied. This having been done, bt a loop, or noose, 
formed by doubling a band of linen, or, which answers as well, of stout 
worsted, be fixed on the part of the limb thus protected, and the ends 
be drawn through the noose ; to these ends the force employed, which 
is usually the muscular power of assistants, is applied. The preferable 
way of applying the noose, is to fix it by means of what is called the 
clove-hitch ; the advantage of which is, that while it holds firmly enough, 
it cannot be tightened by the pulling so as unduly or dangerously to 
constrict the limb. Instead of a noose, a circular band, tightened by a 
screw, is sometimes used, but the former is more convenient and 
efficient. The force should be thus applied, while counter-extension 
is being employed above the joint. The different ways of using coun- 
ter-extension suitable to special dislocations will be afterwards de- 
scribed. 

In some dislocations the muscular power of assistants is insufficient ; 
and in such cases the necessary force is applied by means of pulleys. 
These, being so constructed as to afford great mechanical power, enable 
the operator to carry the extension to any degree he may think judi- 
cious, without the risk of any relaxation or diminution of the force. 
When they are employed, a well-padded belt is fixed round the limb, 
having two straps with rings attached to them ; .the hook of one set of 
pulleys is fixed to the rings, while the hook of the other set is fixed to 
some ring, staple, or other resisting object in the room, and an assistant 
pulls the cord, to which in this method of reduction the whole power is 
applied. 

[Dr. Gilbert, Professor of Surgery in the Pennsylvania Medical 
College, has suggested a very simple yet effective means of applying an 
extending force in dislocations. He thus describes it : " Place the 



234 DISLOCATIONS IN GENERAL. 

patient, and adjust the extending and counter-extending bands as for 
the pulleys ; then procure an ordinary bed-cord or a wash-line, tie the 
ends together, and again double it upon itself, pass it through the ex- 
tending tapes or towels, doubling the whole once more, and fasten the 
distal end, consisting of four loops of rope, to a window-sill, door-sill, 
or staple, so that the cords are drawn moderately tight ; finally pass a 
stick through the centre of the doubled rope, then by revolving the 
stick as an axis or double lever, the power is produced precisely as it 
should be in such cases, viz., slowly, steadily, and continuously." 1 — Ed.] 

The obstacles to reduction are sometimes so considerable that it is 
necessary to employ some previous measures to diminish the power of 
the muscles. This is usually required in attempting to reduce disloca- 
tions of long standing or in robust persons, and in dislocations of the 
hip-joint, where the resistance is always very considerable. The means 
formerly employed for this purpose were, venesection, or nauseating 
doses of antimony, or the warm bath. Of these the former two are the 
most powerful. When the patient is faint or sick, reduction is much 
more easily accomplished ; and if the patient be robust, or the resistance 
very great, there is much less risk in having recourse to either of these 
means than in employing the greater force, which would otherwise be 
necessary. Of all the auxiliaries to extension and counter-extension, 
chloroform is the most powerful, and it is now invariably preferred. It 
prevents pain, facilitates reduction, renders comparatively little force 
necessary, thereby diminishing the danger of injuring texture, and it 
leaves no permanent weakness of system. When extension and counter- 
extension are being employed, the surgeon should use the dislocated 
bone as a lever, and endeavour to press the extremity of it in the direc- 
tion most calculated to promote reduction ; but this should not be 
attempted until extension and counter-extension have been used for 
some time. 

For fulfilling the second indication, that is, to prevent the recurrence 
of dislocation until the ligaments have had time to unite, the joint 
should be kept at rest, in the attitude in which a return of the dis- 
location is least likely to occur in some instances, and with a degree 
of support, which, however, must depend on the situation of the articu- 
lation. The ligaments are more or less lacerated, and require time to 
heal ; and the surrounding muscles, being not unfrequently torn from 
their insertions, must be kept at rest until they regain their attachments, 
otherwise the joint will remain weak in after life. 

The third indication is to prevent, or remove unfavourable symptoms ; 
for the former purpose, rest of the joint and the antiphlogistic regimen 
are required ; for the latter, antiphlogistic remedies proportioned to 
the age and strength of the patient, and the violence of the symptoms. 

IV. The Consequences of an Unreduced Dislocation are important, 
and in some instances the resources of nature in forming an artificial 
joint are considerable. They seem, however, to be much more effective 
in some articulations than in others ; in the orbicular, for example, 
than in the ginglymoid. In the one case, the power of motion is often 

1 Amer. Jour. Med. Scien., No. II. 



COMPOUND DISLOCATIONS. 235 

regained to a considerable extent, whereas in the other, it is almost, or 
sometimes even entirely lost. In orbicular joints the very form of the 
bone gives a facility of moving, and if the displaced head rests on a mus- 
cle, the muscle becomes dense, hollow, ligamentous, smooth, lubricated, 
and of a suitable form for its reception. If it rests on a bone, as, for 
example, on the ilium or scapula, a cavity is formed to receive it, partly 
by absorption of part of the bone on which it rests, and partly by the 
deposition of new bone ; and the cavity is either lined with a dense 
ligamentous matter, or covered with a porcellanous deposit. A cup 
is thus formed for the reception of the head of the displaced bone, 
which loses its cartilage, and generally becomes covered over by the 
porcellanous deposit, which gives a smoothness to the movement of the 
parts on each other. The surrounding cellular tissue becomes condensed, 
and, although less dense and firm than the original capsular ligament, 
yet it serves to connect the . parts of the new articulation with each 
other, and assists in preserving them in the necessary relations. Sub- 
sequently, but always after the lapse of a considerable period, the ori- 
ginal cavity for the reception of the head of the bone becomes changed 
and ultimately very much diminished by the disappearing of its cartilage, 
the gradual filling up of its centre, and the rounding off by absorption 
of its edges. These changes take place earlier, if the new cavity be so 
situated as to encroach during its formation on the old one. In some 
cases the new cavity has been found so completely to surround the head 
of the bone, that it was impossible after death to remove the head without 
fracturing some part of the artificial joint. The resources of nature in 
remedying the effect of an unreduced dislocation are by no means so 
great, when the accident occurs in a ginglymoid articulation. The 
configuration of the bones is such, that the displaced bone cannot play 
so easily on the parts with which it is brought into contact ; and the 
bones are held so firmly by their connexions as not to admit of much 
motion ; hence, more or less of bony anchylosis has been found, on dis- 
section, to be the general result. It is evident, therefore, that the con- 
sequences of an unreduced dislocation materially differ according to the 
nature of the articulation to which the accident has happened. 

COMPOUND DISLOCATIONS. 

When a bone is not only displaced from the articular surface with 
which it is naturally in contact, but is also protruded through the 
external coverings, or when, in addition to displacement, laceration 
exposes to view the cavity of the joint, the injury constitutes a com- 
pound dislocation, which bears the same relation to simple dislocation 
as compound fracture bears to simple fracture. A compound disloca- 
tion may also be complicated with fracture or severe contusion of the 
bones, extensive laceration of the soft parts, rupture of blood-vessels, 
or laceration of, or pressure upon, nerves. These complications are 
very formidable, and excite the greatest anxiety in the mind of the 
surgeon. At one time these were considered cases for amputation ; but 
now a surgeon would not think himself justified in advising amputation 
from the mere circumstance of a dislocation being compound. Petit 
and Pott inculcated the necessity of immediate amputation, and the 



236 COMPOUND DISLOCATIONS. 

practice was for a long time almost invariably adhered to, both in this, 
country and in France ; but the experience of Sir Astley Cooper, the 
late Mr. Hey of Leeds, Mr. Lawrence, and of almost every practical 
surgeon of eminence in the present day, justify a different procedure. 
In determining on the necessity of amputation, the surgeon is guided 
by the extent and nature of the complications, the situation and size of 
the articulation, and the constitution of the patient. The circumstances 
which warrant amputation are, — very serious complications, such as 
dangerous contusion, and extensive, and more especially comminuted, 
fracture ; rupture of important arteries ; very great laceration of soft 
parts, so that the joint is to a great extent laid open; and a weak or 
irritable constitution. The case is also more unfavourable, if the arti- 
culation be in a part of the body where, by reason of the distance from 
the centre of circulation, the process of repair must be feeble. Such 
are the general considerations to be taken into account in judging of 
the propriety and necessity of amputation ; but in every particular 
instance, the surgeon must be guided by the particular circumstances, 
as it is impossible to lay down such a general rule, as would enable him 
to determine in every case that may arise. When amputation is deemed 
necessary, the proper time for its performance is immediately after the 
patient has recovered from the collapse caused by the injury, and before 
inflammatory symptoms and accompanying irritative fever have com- 
menced. The only other period at which it can be performed is not 
only much less favourable, but is also one which may never arrive ; 
namely, when the above symptoms have subsided. The question, there- 
fore, whether or not a limb is to be preserved, is one which calls for an 
early decision. When such cases terminate fatally, it is usually either at 
an early period by gangrene, or by irritative fever, or, at a later period, 
by hectic fever from the continuance of local suppuration and irritation. 
After the subsidence of the irritative fever, while the patient is hectic, 
amputation may be performed : but after the constitution has been 
weakened by the previous symptoms, it is with much less prospect of a 
favourable result. The two dangers which the surgeon has to consider 
in determining the treatment in the first instance are, on the one hand 
unnecessary mutilation if the limb be amputated, and on the other, 
the risk of life from gangrene and irritative fever, if amputation be not 
performed. In persons of sound constitution compound dislocation is 
often treated successfully, and sometimes they recover from very formi- 
dable injuries of this description with very considerable motion of the 
injured joint. 

When an attempt is to be made to save the limb, the bones should be 
reduced, the edges of the wound brought together, and preserved in 
apposition by strips of adhesive plaster, applied in such a manner as 
not to excite by any irritation by pressure ; every effort should be made 
to obtain adhesion of the soft parts, and the local and constitutional 
symptoms be combatted by the appropriate remedies. 






PARTICULAR DISLOCATIONS. 237 



PARTICULAR DISLOCATIONS. 

DISLOCATIONS OF THE LOWER JAW, OR TEMPORO-MAXILLARY 
ARTICULATION. 

The temporo-maxillary articulation is formed of two bones, an inter- 
articular cartilage, and two synovial capsules ; it is furnished with three 
ligaments; it admits of motion upwards, downwards, backwards, for- 
wards, and to either side. 

The two bones are the temporal and lower jaw, the condyloid fossa 
of the former, and the condyloid process of the latter. Each bone, 
where it forms the joint, is covered with a cartilage of incrustation ; be- 
sides which there is an interarticular cartilage dividing the articulation 
into two compartments, — one between the condyloid fossa and the carti- 
lage, the other between the cartilage and the condyloid process ; and each 
division is furnished with a distinct synovial membrane. 

The ligaments are three, — the external lateral, which is in contact 
with bones forming the articulations, and by its deep surface adheres 
to the interarticular surface and synovial apparatus, thus helping to 
preserve the cartilage in its proper situation ; the internal lateral, and the 
stylo-maxillary ; the last two not being in contact with the articulation, 
but completely separated from it by several important structures. 

The jaw is drawn upwards by the temporal, mass3ter, and internal 
pterygoid muscles ; downwards, by the platysma-myoides, digastricus, 
mylo-hyoideus, genio-hyoideus, and genio-glossus muscles ; forwards, 
by the combined action of the two external pterygoid, and one of the 
portions of the masseter ; backwards, by the masseter, and when the os 
hyoides is fixed, by the digastricus, the genio-hyoideus, and genio-hyo- 
glossus, and perhaps very slightly by some of the fibres of the mylo- 
hyoideus ; and laterally, as in the grinding motions of the jaw, by the 
alternate actions of the two external pterygoid muscles assisted by the 
oblique motion forwards given by the internal pterygoid. 

The articulation is liable to three dislocations, namely — 

1st. Complete dislocation on both sides ; 

2d. Complete dislocation on one side ; and 

3d. Partial dislocation of the temporo-maxillary articulation. 

COMPLETE DISLOCATION ON BOTH SIDES. 

Causes. — This dislocation may be caused by a blow upon the chin 
when the mouth is widely opened ; by yawning ; by spasmodic action 
of the external pterygoid muscles, while laughing ; by spasmodic action 
of the same muscles, during the extraction of a tooth, — of which the 
celebrated Mr. Fox, the dentist, met with an example ; or by violently 
or suddenly opening the mouth very wide to receive too large a body, 
— of which Sir Astley Cooper records a case, — two boys were struggling 
for an apple, and the one, in attempting to force it into his mouth, dis- 
located his jaw. When the condyloid process is in its natural position, 
it rests behind the inferior root of the zygoma, which forms the anterior 
part of the condyloid fossa ; but it may be drawn over this root by the 
external pterygoid ; and this is more likely to happen, if the mouth be 



238 



PARTICULAR DISLOCATIONS. 



Fig. 59. 




wide open, when the external pterygoid contracts. The rationale of 

this must at once be evident to every 
one who knows the action of the ptery- 
goid muscles. 

Symptoms. — The patient is unable 
to close the mouth. At first there is 
a considerable distance between the 
front teeth of the upper and lower 
jaw-bones, sometimes as much as an 
inch and a half; but afterwards the 
jaws can be brought closer, although 
the mouth still remains open, in con- 
sequence of the mechanical obstruction 
presented by the relation which is 
produced between the coronoid pro- 
cess of the lower jaw, and the under 
part of the malar bone. The func- 
tions of speech and of deglutition are 
interrupted ; and the salivary glands 
being irritated by the pressure, there 
is consequently a great secretion of 
saliva, which, from the loss of deglu- 
tition, dribbles over the chin. If the 
lower teeth could be brought up, they would be found much in advance 
of the upper. The pain in some instances is not very great ; in others 
excessive. The cheek is stretched and flattened ; the angle of the lower 
jaw is too near the mastoid process of the temporal bone, and a preter- 
natural depression may be felt in front of the external auditory foramen, 
occasioned by the removal of the condyle from its natural situation. 
State of the parts. — The condyloid process, instead of being in its 

natural situation, that is, in the 
Fi g- 60 - condyloid fossa, the articular 

cavity of some writers, behind the 
inferior root of the zygoma (called 
by some the articular eminence), 
is brought forward in front of this 
eminence ; and as the combined 
action of the external pterygoid 
muscles, which have one of their 
insertions into the pterygoid fossa 
immediately beneath the condy- 
loid process, is to bring forward 
the jaw, it is easy to perceive how 
the dislocation may be produced 
by the spasmodic contraction of 
these muscles. 

The coronoid process of the lower jaw is inferior to the under part of 
the malar bone, and pressing against it, presents the mechanical ob- 
stacle to the closing of the mouth, which has been already referred to. 
Treatment. — Various methods of reduction have been adopted. One 




PARTICULAR DISLOCATIONS. 239 

is to introduce the thumbs, and with them to depress the molar teeth, 
while the chin is elevated by the fingers : by this means the condyles 
are depressed, and sent backwards into the cavities in which they are 
naturally situated. Another method is that employed by Mr. Fox, who 
placed a piece of wood about a foot long upon the molar teeth ; then 
raising the end which he held in his hand, and using the teeth of the 
upper jaw as a fulcrum, thus depressed the end which was on the teeth, 
thereby accomplishing reduction on one side ; and afterwards, in the 
same manner, he reduced the dislocation on the other side. A third, 
and by far the most elegant method, is that recommended by Sir Astley 
Cooper, namely, to place a cork on each side, between the molar teeth 
of the upper and lower jaw-bones as far back as possible, and then to 
press up the chin with the hand. The corks act as fulcra, the lower 
jaw as a lever, and the hand applied to the chin as the power. By 
raising the chin, the condyles are pressed downwards and backwards, 
and are thus sent over the articular eminences into their natural situa- 
tions. 

COMPLETE DISLOCATION ON ONE SIDE. 

By this is meant a dislocation in which the condyloid process advances 
over the inferior root of the zygomatic process, or articular eminence, 
on one side. 

In this dislocation the mouth cannot be closed, but it is not so widely 
opened as in dislocation on both sides ; the chin is generally twisted to 
the opposite side, and the incisor teeth are not in a line with the axis 
of the face. From a consideration of the structure of the parts we 
should expect, that in every instance of this injury the chin would be 
evidently turned towards the opposite side ; but Mr. Hey, of Leeds, 
says (at p. 325 of his "Practical Observations on Surgery," third edi- 
tion), " I have repeatedly seen the disease when I could discern no 
alteration in the position of the chin. The symptom which I have found 
to be the best guide in this case, is a small hollow, which may be felt 
behind the condyle that is dislocated, which does not subsist on the 
other." The other symptoms, the state of the parts, and the treatment, 
are precisely the same as in the preceding injury, except that in reduc- 
tion, the cork, or lever of wood, or pressure with the thumb, should be 
used only on one side. To depress both condyles is found, as was first 
mentioned by Mr. Hey, to have a tendency to prevent reduction ; and 
this, no doubt, explains what several surgeons have experienced, namely, 
that reduction is more easily accomplished by using the lever of wood, 
than by other means when the injury is on one side. After reduction, 
the jaw should be for some time supported by a bandage, and the patient 
should be careful not to open the mouth wide for a considerable period. 
Care, indeed, will be ever afterwards necessary in opening the mouth ; 
for when the injury has once happened, a very slight cause will be suffi- 
cient to reproduce it. 

PARTIAL DISLOCATION, OR SUBLUXATION OP THE JAW. 

The signs of subluxation are, a sudden locking of the jaw, the mouth 
being opened slightly and more widely in general on the affected side, 



240 DISLOCATIONS OF THE CLAVICLE. 

and pain at the articulation. The symptoms do not depend on the dis- 
placement of the bones from each other, but on the interarticular car- 
tilage slipping from its proper relation to the condyloid process in 
consequence of relaxation, especially of the external lateral ligament. 
It is met with in persons of a relaxed habit of body, and is usually 
removed by the natural efforts to open or shut the mouth ; but when 
these do not succeed, the back part of the jaw should be pressed directly 
downwards, so that the condyloid process being depressed, the cartilage 
may be replaced in its proper relation to it. In one instance, after this 
plan had failed, remembering the attachment of the external pterygoid 
muscle to the interarticular cartilage as well as to the pterygoid fossa, 
I desired the patient to make an effort to bring forward the lower jaw, 
and the effort very speedily removed the subluxation. Young women 
of relaxed habit often experience a painful snapping at the joint while 
opening and closing the mouth. This, it is believed, is occasioned by 
the ligament failing from relaxation to preserve the parts in their due 
relations ; and the best remedies for its removal are the means most 
likely to increase the tone of the parts, and to improve the general 
health and strength. The shower-bath, preparations of iron, together 
with other treatment for the general health have been useful, and in 
obstinate cases, a blister in front of the ear has been found to produce 
the desired effect. 

DISLOCATION OF THE CLAVICLE AT ITS STERNAL EXTREMITY. 

We have here two bones, the sternum, which is fixed, and the cla- 
vicle, which is so connected with the sternum that its inner extremity 
projects above it, and four ligaments, namely, the anterior sterno-cla- 
vicular, the posterior sterno-clavicular, the interclavicular, and costo- 
clavicular, together with an interarticular cartilage connected more 
closely with the clavicle than with the sternum. Of this articulation 
four dislocations have been known ; but two of them are so extremely 
rare, that of one, Sir Astley Cooper, in his own vast experience, never 
met with an example, although he records a case occurring in the prac- 
tice of another surgeon, in which the dislocation was caused, not by 
external violence, but by disease ; and of the other, so far as my reading 
extends, I have found but one example. The four dislocations are 
arranged in the following order, according to the direction of the cla- 
vicle. 

1. Dislocation forwards, in which the clavicle is thrown forwards on 
the sternum. 

2. Dislocation upwards. 

3. Dislocation backwards. 

4. Dislocation upwards and inwards. 

Symptoms. — In dislocation forwards there is an unnatural tumour, 
or obvious deformity in front of the sternum, which may be made to 
disappear by drawing the shoulders backwards ; but it returns as soon 
as the force is removed ; the distance between the acromion process and 
the mesial line is diminished ; the head is drawn forwards, and turned 
from the affected side to relax the sterno-cleido-mastoideus muscle ; and 
there is inability to raise the upper extremity. The clavicle rests on 



DISLOCATIONS OF THE CLAVICLE. 241* 

the front of the sternum. A partial dislocation in this direction has 
been met with, in which the clavicle is not removed from its articulation 
with the sternum, the ligaments not being sufficiently lacerated to admit 
of complete displacement ; but it projects unnaturally forwards. 

In dislocation upwards the symptoms differ from those of the last 
dislocation merely in the situation of the unnatural swelling, which in 
this instance is in the under part of the neck ; in the other on the front 
of the sternum. 

In dislocation backwards there is an unnatural depression in the 
ordinary situation of the sternal extremity of the clavicle. It may also 
be accompanied by dyspnoea from pressure on the trachea, by dysphagia 
from pressure on the oesophagus, and by impeded circulation and pain 
from pressure on the vessels and nerves. This dislocation is so very 
rare, that Sir Astley Cooper says he never met with a single case as the 
result of injury, but refers to a case which occurred in the practice of 
Mr. Davie, surgeon at Bungay, Suffolk, in which the dislocation was 
caused by the bone being pressed forward at its outer extremity, arising 
from deformity of the spine. In this case, Mr. Davie was obliged 
to saw off the inner extremity of the clavicle, in order to relieve the 
dyspnoea and the other distressing symptoms caused by the pressure on 
the parts at the under portion of the neck. It has, however, been since 
ascertained that this injury may be produced by violence, and in the 
"Medical and Surgical Journal" for October, 1841, several cases are 
recorded. The ligaments in this dislocation are more or less ruptured. 

Treatment. — In dislocation forwards, the surgeon should endeavour 
to bring forwards the outer extremity of the clavicle, at the same time 
pressing backwards the inner extremity. In many instances the clavicle 
has been drawn off the sternum by pulling the shoulder backwards. 

In dislocation backwards, it is necessary to draw the shoulders very 
much backwards, and as far as possible from the sternum. In all these 
dislocations the clavicle may be drawn outwards by drawing the shoulder 
outwards. In dislocation upwards, after the shoulder is drawn out- 
wards the surgeon should raise the outer and depress the inner extre- 
mity of the clavicle. For preserving the bone in its normal situation, 
and at perfect rest, the best retentive apparatus is that used in fractures. 
The cure is seldom so complete as in dislocations of other joints, and 
often some deformity remains, in consequence of the ligaments not pro- 
perly uniting. Professor Samuel Cooper gives the following particulars 
of the dislocation upwards and inwards. He says, "My friend, Mr. 
Morton, of University College, has favoured me with the particulars of 
an unusual dislocation of the sternal extremity of the clavicle, the dis- 
placement of it being upwards and inwards. Etienne Care'ron, aet. 39, 
mason, admitted. into the hospital of La Charitd, on account of an in- 
jury which was caused by his having been violently squeezed between a 
wall and a cart, in such a manner that the left shoulder was thrust in- 
wards with great force. On examination, the sternal extremity of the 
clavicle was found to have been displaced from its natural situation, and 
was now placed above the upper edge of the sternum, producing a slight 
deformity in the contour of the lower part of the front of the neck. It 
seemed from the description of the accident which was given by the 



242 DISLOCATIONS OF THE CLAVICLE. 

patient, that the force producing the injury had acted in such a direc- 
tion as to push the sternal extremity of the dislocated bone upwards 
and behind the sternal portion of the sterno-cleido-mastoid muscle. The 
articular surface of the internal extremity of the dislocated clavicle lay 
opposite to that of the clavicle of the sound side, and was supported by 
the superior border of the sternum. The attachment of the sterno- 
cleido-mastoid muscle to the first bone of the sternum did not appear to 
have suffered any laceration. M. Velpeau considered it to be very pro- 
bable, that the dislocation was in the first place backwards, but that the 
force continuing to act, the end of the clavicle was afterwards driven 
upwards and across the front of the root of the neck, and behind the 
sterno-cleido-mastoid muscle. The dislocation was reduced in the usual 
manner, and the apparatus of Desault for fractured clavicle employed 
to retain the bone in its proper place. The bandages used w r ere steeped 
in a solution of ' dextrine,' which when dry rendered the whole immo- 
vable." 

DISLOCATION OF THE CLAVICLE AT ITS SCAPULAR EXTREMITY. 

The external extremity of the clavicle articulates with the acromion 
process of the scapula. The ligaments which more immediately bind 
these bones together are two ; the superior and inferior acromio-clavi- 
cular ligaments. The two portions of the coraco-clavicular ligament, 
though not attached to the parts forming the articulation, still contri- 
bute much to prevent the frequent occurrence of dislocation by causing 
the two bones to follow each other in their motions. The scapular ex- 
tremity of the clavicle is liable to only one dislocation, namely, upw ards, 
in which it rests on the acromion process of the scapula. 

Symptoms. — Diminution of the space between the apex of the acro- 
mion process and the central point of the sternum ; an obvious defor- 
mity produced by the outer extremity of the clavicle, which, according 
to Sir Astley Cooper, may be best ascertained by tracing the spine of 
the scapula from within outwards ; in doing which the finger will be in- 
terrupted by the outer extremity : inability of the patient to raise the 
arm ; and unnatural flatness of the shoulder. By drawing the shoul- 
ders very forcibly backwards, these symptoms may be made to disap- 
pear for the time. 

State of the parts. — The superior and inferior acromio-clavicular liga- 
ments are ruptured. The peculiarity of the displacement is, that when 
the two portions of the coraco-clavicular ligaments are ruptured, the 
falling down of the shoulder is greater than if the two proper ligaments 
be ruptured. 

Treatment. — The object is to bring the shoulders backwards. Sir 
Astley Cooper recommends the surgeon to place his knee between the 
shoulders of the patient, and forcibly draw them backwards and out- 
wards. According to Mr. Liston, the best retentive apparatus is the 
same as for fractured clavicle ; and which must be continued for many 
weeks, as the ligaments are slow in uniting. In dislocation of either 
extremity of the clavicle, even when treated by the most experienced 
surgeons, some deformity will almost always remain ; but the patient 
will recover the motion of his arm. 



DISLOCATIONS OF THE SHOULDER JOINT. 243 



DISLOCATION OF THE SHOULDER JOINT. 

The scapulohumeral articulation is formed of portions of two bones, — 
the glenoid cavity of the scapula, and the head of the humerus. The 
ligaments entering into its formation are three — the capsular, the ac- 
cessory of some, the coraco-humeral of other anatomists, and the glenoid. 
An intimate knowledge of the anatomy of this articulation, and of the dis- 
position of the muscles for effecting its movements, is of the utmost im- 
portance ; for experience has proved that, in consequence of its varied 
and extensive movements, the shoulder joint is more frequently disloca- 
ted than any other of the articulations, and even, as some maintain, 
than all the others collectively. The number of dislocations to which 
it is liable, though usually stated to be four, we shall find to be five, 
three of which are complete, and two partial. The direction of the hu- 
merus is made the basis of the nomenclature. 

1. Dislocation downwards, or downwards and inwards, or into the 
axilla. 

2. Complete dislocation forwards. 

3. Partial dislocation forwards. 

4. Dislocation backwards. 

5. Partial dislocation upwards. 

With regard to the comparative frequency of these dislocations, it has 
been ascertained that the first occurs most frequently ; the second and 
third are not so common ; the fourth is very rare ; and of the fifth, not 
more than one or two cases are recorded. 

I. DISLOCATIONS DOWNWARDS. 

Exciting Causes. — A fall from a great height upon the top of the 
shoulder ; a blow upon the upper part of the humerus, when the arm is 
extended ; or the forcible and violent upraising of the hand or elbow, by 
which the head of the bone is pressed against the under part of the cap- 
sular ligament. It has also been caused by the violent contraction of 
the deltoid, as in raising a heavy body ; for while the deltoid raises the 
arm, the capsular ligament is made the fulcrum ; and if this gives way, 
dislocation downwards may be produced. 

Symptoms. — The natural roundness of the shoulder is lost, owing to 
the head of the bone no longer supporting the deltoid muscle ; the acro- 
mion process is unusually large and prominent ; and a very striking 
symptom, which cannot fail to be perceptible on examination, is a vacuity 
under the acromion. There is also a want of that depression or hollow at 
the insertion of the deltoid, which is very conspicuous when there is 
no dislocation. The fibres of the deltoid, instead of giving the round- 
ness to the shoulder, and going in a convex direction over the head of the 
humerus, in their way from their origins to their insertion into the del- 
toid eminence, go in a straight direction ; and if they be felt through 
the integuments, -it will be found that they are not only flat, but also 
exceedingly tense, — a condition which, as will afterwards appear, offers 
one of the obstacles to reduction. The rationale of these symptoms will 
be easily understood, when it is remembered that the head of the bone, 
instead of resting, as it naturally does, in the glenoid cavity, is sent 



244 



DISLOCATIONS OF THE SHOULDER JOINT, 



down into the axilla, and consequently the distance between the inser- 
tion and the origins of the deltoid is greater than natural, and its fibres 
are therefore put violently on the stretch. 

Fig. 61. 




All the above-mentioned symptoms are observable about the upper 
and outer portion of the shoulder. On the opposite aspect of the joint, 
namely, in the axilla, there is an unnatural tumour caused by the head 
of the bone, which is rendered more perceptible by effecting abduction 
of the elbow. The surgeon may not be very sensible of this symptom 
while the patient holds his elbow as near as he can to his side : but the 
moment the elbow is pressed outwards, the head of the bone sinks in 
the axilla, and can be very distinctly felt. Elongation of the affected 
arm is particularly well marked ; for ascertaining which, take the apex 
of the acromion and the outer condyle of the humerus, as two fixed 
points for measurement. The forearm is at a right angle with the arm 
and the elbow, the situation of which should be particularly observed, 
as it serves for a diagnostic symptom in distinguishing the different 
dislocations of the shoulder from each other, is neither directed back- 
wards nor forwards, but is in a line with the long axis of the body, and 
removed from the side. The patient cannot, by a voluntary effort of 
the muscles of the affected arm, bring the elbow to the side ; and if the 
surgeon forcibly press it inwards, the patient complains of great pain 
from the head of the bone being pressed against the nerves of the axilla, 
and when left to itself the arm hangs away from the trunk. The 
patient has an inclination to support the elbow by the hand, when 
standing ; and when sitting, to rest it on the knees. A very striking 
symptom is an alteration in the direction of the long axis of the hume- 
rus. In the natural state of the parts when the arm is by the side, the 
axis of the humerus is parallel to the side, and the arm seems to come 



DISLOCATIONS OF THE SHOULDER JOINT. 245 

down from the glenoid cavity ; whereas in this dislocation the axis is 
placed obliquely in regard to the side, and the humerus seems to come 
out from the trunk instead of from the glenoid cavity. The patient 
has lost the power of performing the ordinary movements of the joint, 
and not only is he unable, by voluntary effort, to raise his arm : but it 
is also, in a great measure, immovable to the surgeon, especially up- 
wards and downwards, remaining stiff in its unnatural position ; and the 
patient, when he wishes to alter its situation, moves the whole trunk 
and extremity in mass. Sometimes the surgeon can move it slightly 
backwards and forwards, while in other directions, motion is difficult 
and attended with great suffering. It is proper, however, to add, that 
in very old persons, or in relaxed feeble habits of body, the immobility 
of the arm to the surgeon may not be so perceptible. In addition to 
the above symptoms, there is often tingling at the points of the fingers, 
with numbness of the whole limb, and oedematous swelling arising from 
the compression of the axillary plexus and interruption of the circula- 
tion. On moving the limb a slight crepitus is sometimes perceived, but 
on continuing the motion it ceases to be perceptible. The crepitus is, 
probably, owing to the effusion of serum, and the escape of synovia 
into the cellular tissue. This soft crepitus is easily distinguished from 
the hard crepitus of fracture, which, however, has been sometimes met 
with in dislocation of the shoulder, and is believed to depend on one or 
more of the tendinous attachments of the muscles having, during their 
disruption, torn away a portion of their osseous attachments. Many of 
these appearances, although very distinctly marked at first, frequently 
become obscured for a time by extravasation of blood and inflammatory 
swelling, which often supervene ; but when these symptoms subside, 
they again become distinct and decisive. 

State of Parts. — For conveying to the reader an idea of the state of 
the parts, I shall give the result of two dissections by Sir Astley Cooper, 
one by Sir Philip Crampton, and one by myself. Sir Astley Cooper 
says, — " I have dissected two recent cases of this dislocation. A sailor 
fell from the yard-arm on the ship's deck, injured his skull, and dis- 
located the arm into the axilla ; he was brought into St. Thomas's 
Hospital, and expired immediately after he was put to bed. On the 
following day I obtained permission to examine his shoulder, which I 
removed from the body for the purpose of obtaining a more minute ex- 
amination, and the following were the appearances which I found. On 
removing the integuments, a quantity of extravasated blood presented 
itself in the cellular membrane, lying immediately under the skin, and 
in that which covers the axillary plexus of nerves, as well as in the 
interstices of the muscles, extending as far as the cervix of the humerus 
below the insertion of the subscapularis muscle. The axillary artery 
and plexus of nerves were thrown out of their course by the dislocated 
head of the bone, which was pushed backwards upon the subscapularis 
muscle. The deltoid muscle was sunken with the head of the bone ; 
the supra and infra-spinati were stretched over the glenoid cavity and 
inferior costa of the scapula. The teres major and minor had under- 
gone but little change of position ; but the latter, near its insertion, 
was surrounded by extravasated blood. The coraco-brachialis was un- 
injured. In a space between the axillary plexus and the coraco-bra- 



246 DISLOCATIONS OF THE SHOULDER JOINT. 

chialis, the dislocated head of the bone, covered by its smooth articular 
cartilage, and by a thin layer of cellular membrane, appeared. The 
capsular ligament was torn on the whole length of the inner side of the 
glenoid cavity, and would have admitted a much larger body than the 
head of the os humeri through the opening. The tendon of the sub- 
scapulars muscle, which covers the ligament, was also extensively torn. 
The opening of the ligament, through which the tendon of the long 
head of the biceps passed, was rendered larger by laceration, but the 
tendon itself was not torn. The head of the os humeri was thrown on 
the inferior costa of the scapula, between it and the ribs, and the axis 
of its new situation was about an inch and a half below that of the 
glenoid cavity from which it had been thrown." 

The second case which Sir Astley Cooper had an opportunity of 
examining, was one in which the dislocation had existed for five weeks, 
and Sir Astley believed that the poor woman died from violence used 
in the unsuccessful efforts to accomplish reduction by extension. Sir 
Astley says, " The capsular ligament had given way in the axilla be- 
tween the teres minor and subscapularis muscles ; the tendon of the 
subscapulars was torn through at its insertion into the lesser tubercle 
of the os humeri, and the head of the bone rested upon the axillary 
plexus of nerves, and the artery. Having determined these points by 
dissection, I next endeavoured to reduce the bone, but finding the re- 
sistance too great to be overcome by my own efforts, I became very 
anxious to ascertain its origin. I therefore divided one muscle after 
another, cutting through the coraco-brachialis, teres major and minor, 
and infra-spinatus muscles ; yet still the opposition to my efforts re- 
mained, and with but little apparent change. I then conceived that 
the deltoid must be the chief cause of my failure, and by elevating the 
arm I relaxed this muscle, but still could not reduce the dislocation. I 
next divided the deltoid muscle, and then found the supra-spinatus 
muscle my great opponent, until I drew the arm directly upwards, when 
the head of the bone glided into the glenoid cavity. The deltoid and 
supra-spinatus muscles are those which most powerfully resist reduction 
in this accident." 

Sir Philip Crampton records an examination which he made by dis- 
section, of a recent dislocation downwards in a labouring man, who was 
brought to the Dublin Infirmary in 1808 in a dying state, owing to 
injuries received by the fall of a wall. The dislocation was of the right 
shoulder, and death took place in about two hours. The head of the 
humerus was lodged on the neck of the scapula and upper part of the 
inferior costa, and surrounded by cellular tissue extremely ecchymosed. 
The head of the bone had pressed down the teres minor, and in its 
descent had passed through the subscapularis muscle, the fibres of 
which embraced the neck of the bone. The fibres of the subscapularis 
were also partly torn up from the scapula. The triceps crossed the 
neck of the humerus on its dorsal side, and the coraco-brachialis and 
short head of the biceps described a curve on its sternal side. The 
tendon of the long head of the biceps remained in its groove, but its 
sheath was partially lacerated. The tendons of the supra and infra- 
spinati, and of the teres minor, were completely torn off from the 
humerus, and along with them the surface of the greater tubercle. The 



DISLOCATIONS OF THE SHOULDER JOINT. 



247 




capsular ligament was torn from the lower part of the neck of the hu- 
merus to the extent of half its circumference, and the axillary vessels 
and nerves were made to describe a curve backwards, by the presence 
of the head of the bone which was in contact with them. 

When I taught anatomy in this University, a body, apparently that 
of a labouring man, was brought 

to the dissecting-room, which pre- Fig. 62. 

sented all the appearances of a 
dislocation downwards of the 
shoulder. I made a careful dis- 
section of all the parts, and the 
preparation is still in my posses- 
sion. The dislocation must have 
been of very long standing, as the 
glenoid cavity was a good deal 
filled up, and a new shallow cavity 
formed on the neck and upper 
part of the inferior costa of the 
scapula for the head of the hume- 
rus, which had lost its cartilage, 
and was covered over with porcel- 
lanous deposit. The cellular tissue 
was thickened about the ball, to 
form a capsular ligament ; and 
the precise position into which the 
head of the humerus was pushed, 
in escaping from its socket through the under part of the capsular liga- 
ment, was behind the subscapulars, in front of the teres minor and long 
head of the triceps, and upon the 

teres major and latissimus dorsi Fi &- 63 « 

muscles, with the axillary vessels 
and nerves to its inferior and 
inner aspect. As the body was 
brought to the dissecting-room at 
the period when subjects were pro- 
cured by exhumation, I found it 
impossible to procure a history of 
the case. 

Treatment. — Various methods 
are employed for accomplishing 
reduction. 

By the Knee in the Axilla. — 
If the dislocation be recent, and 
in a thin, attenuated subject, let 
the patient be seated on a low 
chair, and let the. surgeon, placing 
himself beside him with his foot 
resting upon the chair, put his 
knee into the axilla, and while 
with one hand he presses upon the 
acromion, with the other let him depress the elbow, thus making his 




248 



DISLOCATIONS OF THE SHOULDER JOINT. 



knee a fulcrum, and the humerus of the patient a lever. I have often 
reduced dislocations by this method with the greatest ease. 

By the Heel in the Axilla. — This is a mode which has been very 
strongly recommended by Sir Astley Cooper, and is often attended 
with success. The patient is placed in the recumbent posture on a 
couch, and the surgeon having applied a wetted roller round the lower 
part of the arm, and having tied a handkerchief or towel round the arm 
above the wetted roller, places himself on the same seat with one foot 
resting on the floor, and the heel of the other in the axilla, and then 
extends the arm by pulling the towel or handkerchief. 

In this method of reduction there are various ways of applying the 
extending force. One is that just described ; another is to apply the 
handkerchief to the wrist ; a third is for the surgeon, having put a 
skein of worsted round the arm, to pass his head through the double of 
the worsted, and make it rest on the back of his neck, and while pulling 
the arm to raise up and draw back his own body, by which means he 

Fig. 64. 




will be able to exert a much greater extending force than by either of 
the two former ways ; and a fourth plan, which may be adopted in cases 
of considerable difficulty, is to make the assistants give additional ex- 
tending force by pulling the ends of the towel or handkerchief fixed 
round the arm. It has been remarked that a great advantage of this 
method of reduction is, that the surgeon, both at the long end of the 
lever and at the fulcrum, has his sense of touch to appreciate the effect 
produced by the force, and is able, therefore, at once to modify its 
application as circumstances may require ; and as soon as the heel 
detects the slightest change in the position of the bone, he can imme- 
diately direct the humerus towards the glenoid cavity. 

By Manual Extension. — The patient being placed in a chair, the 
first object is, to fix the scapula so as to afford the necessary counter- 
extension. This may be done by applying the double of a sheet under 
the axilla, carrying it over the opposite shoulder, and fixing it to some 
post or resisting object on the opposite side of the patient to that on 
which the injury is situated. If the sheet be not very much pressed up 
to the axilla, and its extremities be raised up so as to be on a level with 



DISLOCATIONS OF THE SHOULDER JOINT. 249 

the opposite shoulder, it will fix only the body and under angle of the 
scapula, and leave the parts near the glenoid cavity to be drawn from 
the chest by the extending force applied to the arm. The more elegant 
method of affording counter-extension is by a well-padded ring of leather, 
having attached to it two belts, by which it may be fastened to a post 
or any resisting object ; and the trunk and scapula being thus fixed, the 
necessary counter-extension is obtained. The next object is to employ 
extension ; and, for this purpose, a few turns of a wetted roller should 
be applied to the arm above the elbow, and a band of worsted, or a 
piece of linen, fastened upon it by the clove-hitch knot ; for this knot, 
while tight enough to prevent slipping, cannot become so tight as to 
produce dangerous compression. The arm should be elevated to the 
horizontal position, to relax the deltoid and supra-spinatus muscles ; 
and extension should be afforded by assistants drawing the ends of the 
worsted, or towel, or linen, gradually, slowly, and steadily; and after 
the extension has been kept up for several minutes, and while it is still 
so, the surgeon, placing his foot upon the chair in which the patient 
sits, should put his knee into the axilla, and with one hand press the 
acromion downwards and inwards, and with the other slightly press 
down the elbow, pushing the head of the bone upwards by means of the 
knee, which can be done by raising the foot so as to rest it on the toes. 
During the whole time the surgeon, before the introduction of Chloro- 
form, used to divert the patient's attention by engaging him in con- 
versation ; but with such an invaluable auxiliary, that practice is no 
longer needful. 

By means of Pulleys. — If it be probable, from the muscular strength 
of the patient, or from the time that has elapsed since the occurrence of 
the dislocation, that very considerable extension will be required, it is 
advisable to afford it by means of pulleys. Previously to their use, the 
surgeon will diminish the degree of resistance to be overcome, by bring- 
ing the patient fully under the influence of chloroform. The necessary 
counter-extension can be very conveniently afforded by the plan recom- 
mended in the description of the former method of reduction. The ex- 
tending force may be applied to the lower part of the arm, by placing 
round it a few turns of a wetted roller, over which a belt of leather is 
fastened, with two straps extending from it, at the extremity of each of 
which is a ring, to which the hook at one end of the pulleys is fixed, 
while the hook attached to the other set of pulleys is affixed to a ring in 
some resisting object, care being taken that the ring is on a level with 
the line of counter-extension. Extension is then produced by pulling 
the cord of the pulleys. This method is useful for allowing the applica- 
tion of considerable extending force, which, however, might be afforded 
in the ordinary way, by increasing the number of assistants ; but the prin- 
cipal advantage of the pulleys is, that by them the force can be applied 
steadily and gradually ; whereas, when extension has to be long kept up 
by the usual method, the assistants become wearied, and the extension is 
unequal and accompanied with sudden jerks. The pulleys so greatly in- 
crease the force, that few assistants are required. The proper method of 
applying extension by the pulleys, is to draw the cord slowly and steadily, 
until the extension becomes considerable, to keep up the same degree of 
extension for several minutes, and then to increase it again gently. When 



250 DISLOCATIONS OF THE SHOULDER JOINT. 

considerable extension has been employed, the surgeon should, by placing 
his knee in the axilla, with one hand on the acromion, and the other on 
the lower part of the arm, endeavour to replace the head of the bone in 
the manner described in the last section. In this method the surgeon, 
although sensible of the return of the bone into its natural situation, 
seldom finds it return with a snap, as when reduction is accomplished 
by the other methods. 

II. COMPLETE DISLOCATION FORWARDS. 

Symptoms. — In this dislocation, there is the absence of the natural 
roundness of the shoulder, the acromion more pointed, and the vacuity 
greater than in the former dislocation. There is an unnatural flatten- 
ing of the shoulder behind, and an unnatural tumour, caused by the 
head of the bone, below and to the sternal side of the coracoid process, 
and below the middle of the clavicle. The elbow is removed from the 
trunk, and drawn a little backwards ; and the long axis of the humerus, 
instead of being parallel with the trunk, and directed upwards to the 
glenoid cavity, inclines towards the trunk, and extends upwards to a 
point underneath the middle of the clavicle. The forearm is at a right 
angle with the arm. The pain is less than in the former dislocation, 
but the motions of the joint are much more restrained ; for any move- 
ment of the arm backwards is prevented by the resistance of muscles, 
movement outwards by the clavicle opposing the head of the bone, and 
motion forwards by the head of the bone striking the coracoid process. 

With regard to another symptom, namely, whether the arm be short- 
ened or lengthened, surgical authorities are divided. According to Sir 
Astley Cooper, the arm will be somewhat shortened, but he does not, 
in any of the cases recorded in his work, mention the state of this symp- 
tom, although it must no doubt have been from what he observed in 
those cases that he arrived at the above conclusion. In a very interest- 
ing case recorded by Sir Philip Crampton, — a case well worthy of atten- 
tion, inasmuch as it settles another disputed point, which will presently 
be mentioned, the axis of the head of the bone was nearly a quarter of 
an inch higher than that of the glenoid cavity : the arm, therefore, must 
have been shorter than natural. 

On the other hand, Desault and Malgaigne maintained that there 
would be elongation ; and Baron Dupuytren, although at one time of 
opinion that the arm could be elongated only in dislocation downwards, 
afterwards agreed with Desault and Malgaigne, and stated, that after 
dissecting the ligaments in a recent joint, and producing dislocation, he 
found the arm had lengthened as much as half an inch. 

There is a point, concerning which, for a considerable time, there 
existed much difference of opinion, namely, whether complete dislocation 
forwards be a primary or consecutive dislocation, — that is, whether the 
bone can be sent out at once by violence from the glenoid cavity to the 
situation which it occupies in this dislocation ; or whether it be first 
dislocated downwards, and suffer a secondary displacement upwards, by 
the muscles drawing it upwards and inwards, as far as the clavicle will 
allow. Some have gone so far as to say, that the head of the bone can- 



DISLOCATIONS OF THE SHOULDER JOINT. 



251 



not get into the position it occupies in this dislocation, except by suffering 
a secondary displacement, after having first been forced downwards. 
Others, for example, Desault, Petit, Dupuytren in France, and the late 



Fia;. 65. 




Mr Hey, and Professor Samuel Cooper in this country, did not deny the 
possibility of its being primary, but they believed, as will be seen by a 
perusal of their writings, that it is in fact very seldom primary, and 
almost always consecutive to dislocation downwards. It is very evident 
that Sir Astley Cooper considered this a primary dislocation. The case 
recorded by Sir Philip Crampton, which will be described in mentioning 
the state of the parts, very clearly proves that, in some cases at least, 
this dislocation is primary. 

State of the Parts. — In the third volume of the " Dublin Journal of 
Medical Science," there is a case of undoubted primary dislocation 
recorded by Sir Philip Crampton, which is interesting, not only as set- 
ting at rest the long-disputed question above-mentioned, but also as being 
the first recorded dissection of the parts in an example of recent dislo- 
cation forwards. " The head of the humerus was lodged on the inner side 
of the neck of the scapula, to the sternal side of the root of the coracoid 
process, and extending up nearly as far as the notch in the superior 
costa. The capsular ligament was perfectly entire in the direction of 
the axilla, showing that the bone could not have been sent first to the 
axilla and afterwards to the situation here described. The opening in 
the caspular ligament was on its inner side, and was caused by its being 
torn from the glenoid cavity, the rent extending from the supraspinatus 
muscle above to the under part of the subscapularis muscle below. 



252 



DISLOCATIONS OF THE SHOULDER JOINT. 



Fig. 66. 




The supra and infra-spinati were much on the stretch, but not 

lacerated, and the subscapularis muscle 
was partly detached from the upper and 
the anterior parts of the subscapular fossa, 
and pressed downwards, so that its fibres 
in a curved manner embraced the neck of 
the bone. The axis of the head of the 
bone was scarcely a quarter of an inch 
above the centre of the glenoid cavity, and 
the vessels and nerves were on the sternal 
side of the humerus." Mr. Key made a 
dissection of a shoulder w r hich had long 
been dislocated inwards. The glenoid 
cavity was completely filled up by liga- 
mentous matter, and the head of the hu- 
merus was situated under the clavicle to 
the sternal side of the root of the cora- 
coid process, in contact with the venter of 
the scapula, from which the subscapularis 
muscle was at that part torn off, and separated from the ribs by that 
muscle and the serratus magnus muscle. A new socket and complete 
capsular ligament had been formed. 

I believe that in complete dislocation inwards, the head of the bone 
will generally be in the position described above, with the pectoral 
muscles before it, and the axillary vessels and nerves to its sternal side. 
Treatment. — The reduction is to be effected by the means recom- 
mended in describing the methods by manual extension, and by pulleys, 
in the former dislocation, with the two following peculiarities : — First, 
that the extension should be made downwards and outwards, in the line 
of the unnatural direction of the axis of the humerus, until the head of 
the bone be below the coracoid process ; then the extension should be 
continued with the arm raised to the horizontal position. Second, that 
after extension has been applied for a considerable time, and while it is 
still being continued, the surgeon should endeavour to replace the head 
of the bone, by employing the humerus as a lever, pressing the lower 
part of it forwards, and its head backwards in the direction of the glenoid 
cavity ; and while doing so, he should also rotate the arm. This can be 
most effectually done by using the forearm as a lever, having it bent at 
a right angle with the arm, in order to prevent stretching of the biceps, 
which would be an obstacle to reduction. 

In attempting replacement in this, as in every other dislocation, the 
extension and counter-extension must always be in a line with each other. 

III. PARTIAL DISLOCATION FORWARDS. 

Symptoms. — The head of the bone is drawn forward against the 
coracoid process, where there is an unnatural tumour, whilst there is a 
depression opposite the back part of the shoulder joint. The posterior 
half of the glenoid cavity is perceptible to the fingers, whilst the long 
axis of the humerus is in front and in a line with the coracoid process. 
The elbow is slightly removed from the side, and is in a line behind the 



DISLOCATIONS OF THE SHOULDER JOINT. 253 

long axis of the body. The arm can partial! y perform such movements 
as do not require its elevation, but it cannot be raised. 

State of the Parts. — The head of the bone is on the scapular side of 
the coracoid process, and rests against it and the edge of the glenoid 
cavity, where, in an unreduced dislocation, a new cavity has been found 
formed for its reception. It seems possible for this dislocation to occur 
without the capsular ligament being torn through ; but in dissecting an 
old dislocation, it was found that the ligament had been ruptured and 
become attached to the coracoid process. The latissimus dorsi and two 
teres muscles are put upon the stretch, and the pectoralis major, except 
some of its inferior fibres, is relaxed. The spinati muscles are slightly 
on the stretch, and the posterior fibres of the deltoid are extended, 
while the anterior are relaxed. 

Treatment. — Reduction is accomplished in the same manner as in the 
preceding injury, namely, by counter-extension, extension, and a lever- 
like motion of the humerus ; less force, however, is required. 

IV. DISLOCATION BACKWARDS. 

Dislocation of the head of the humerus on the dorsum of the scapula 
is so rare an accident, that Desault had never seen an instance of it ; 
Baron Boyer met with it but once in the living body ; only two cases 
occurred at Guy's Hospital in thirty-eight years ; in the same number 
of years Sir Astley Cooper met with two cases, and not more than four 
cases occurred in his practice during his whole professional career ; and 
Mr. Lawrence, in his lectures, delivered at St. Bartholomew's Hospital 
in 1830, states that at that time he had never seen the humerus 
dislocated backwards. Two cases are reported from the Middlesex 
Hospital ; one from the North London Hospital ; Mr. Toulmin of Hack- 
ney met with a case ; Mr. C. M. Coley of Bridgeworth, with two ; I 
have met with two examples, and there are on record a very few other 
cases, to the particulars of which I may have occasion to refer. 

Causes. — In one of the cases seen by Sir Astley Cooper, the injury 
was produced by pushing a person violently with the arm elevated. Of 
the two cases which occurred at Middlesex Hospital, the one was caused 
by a heavy box from the top of a bedstead falling on the hand of the 
person while the arm was elevated ; the other, in a woman ninety-four 
years of age, was occasioned by a fall on the front of the shoulder, in 
consequence of having trodden on some orange peel. Mr. Toulmin's 
case was in an unusually muscular gentleman, and was caused by a fall 
from his horse. Of the cases narrated by Mr. Coley of Bridgeworth, 
one was caused by the man being pulled down by a calf which he was 
driving, a cord which he held fast in his hand being tied to one of the 
animal's legs ; the other by the person being dashed from his horse 
against a tree, the shock being received on the front of the shoulder. 
In a case of this dislocation, of long standing, in which Mr. Key had 
an opportunity of making a minute examination of the state of the 
parts after death, the injury was caused by spasmodic contraction of the 
muscles during an epileptic fit. The exciting causes^)f the other cases 
recorded are not mentioned. 

Symptoms. — The injury is characterized by the absence of the 
natural roundness of the shoulder, unnatural prominence of the aero- 



254 



DISLOCATIONS OF THE SHOULDER JOINT. 



mion process, with depression under it ; unnatural flatness of the ante- 
rior part of the shoulder, together with a stretched appearance of the 
skin at that part, and an unnatural tumour on the dorsum of the sca- 
pula underneath the spine, caused by the head of the humerus, which 
can be very distinctly felt. As to the precise direction of the long axis 
of the arm and the position of the elbow, surgeons are at variance. In 
the cases mentioned by Mr. Coley and Mr. Toulmin, the elbow was for- 
ward and close to the side. In one of the cases admitted into Middlesex 
Hospital, the arm was close to the side, and in a line with the long axis 
of the body. In the other recorded cases the precise position of the 
elbow is not stated. In one of the cases which I had an opportunity of 
seeing, the elbow was directed forwards ; in the other, it was merely 
removed from the side of the body. The long axis of the humerus is of 
course directed to the dorsum of the scapula, and the position of the 
arm and elbow, as might be expected, from considering what muscles 
would thus be put upon the stretch, is for the long axis of the arm to 
extend downwards and forwards, with the elbow removed from the side, 
and in a line before the long axis of the body. Some surgical autho- 
rities give this direction of the long axis of the arm, and this position of 
the elbow, as symptoms, without stating whether they do so from reason- 
ing on the unnatural condition of the muscles, or from observation. It 
is not more difficult to explain an occasional deviation from this attitude 
in this dislocation, than it is to explain how in some very rare instances 
the elbow is nearly close to the side in dislocation downwards, although, 
in by far the greater number of examples, it is removed from the side to 
diminish the painful tension of the deltoid muscle. 

State of the Parts. — The head of the bone lies on the dorsum of the 
scapula, the capsular ligament is ruptured, the muscles in front of the 

joint are stretched, and the infra- 
Fig- 67 - spinatus and teres minor are torn up 
from the scapula, before the head of 
the bone can arrive at its unusual 
situation. In the case in which the 
injury was caused by spasmodic con- 
traction of the muscles in an epileptic 
fit, and of which a dissection was 
made by Mr. Key, the gentleman 
lived for seven years after the acci- 
dent, but the dislocation could not 
be kept reduced, and he never re- 
sumed the use of his arm. On in- 
spection after death, it was found 
by Mr. Key, that the explanation of 
the impossibility of keeping it re- 
duced, was laceration of the tendon 
of the subscapulars muscle, and its 
adhesion to the edge of the glenoid 
cavity with very imperfect union. 
The anterior part of the capsular 
ligament was torn at the insertion 
of the subscapularis, and the posterior part was carried back with the 




DISLOCATIONS OF THE SHOULDER JOINT. 255 

bone, which, instead of resting far back on the dorsum of the scapula, 
rested on the posterior edge of the articular surface, and on the inferior 
costa close to the articulation. 

Treatment.— In two of the recorded cases of this injury, Sir Astley 
Cooper accomplished reduction by raising the hand and arm, and turn- 
ing the hand backwards behind the head. In another instance this 
method was tried without success, and the bone was replaced by exten- 
sion of the arm, the scapula being fixed by placing the heel in the 
axilla. In another, reduction was effected by extension from the wrist 
in the direction of the displaced bone without the heel in the axilla ; 
and in the remaining cases, with the exception of one which remained 
unreduced, the bone seems to have been replaced by extension and 
counter-extension, and in some of them with very little difficulty. 

The general principles already mentioned as applicable to reduction 
of dislocation downwards, in the description of the methods by manual 
extension and by pulleys, are applicable to this luxation ; but the ex- 
tension should be made forwards and outwards, with the arm raised to 
a horizontal position; and while the extension and* counter-extension 
are being applied, the surgeon should endeavour to direct the head of 
the bone upwards and forwards by employing the humerus as a lever, 
pressing the knee against the upper and back part of the humerus, and 
drawing the elbow a little backwards. 

V. PARTIAL DISLOCATION UPWARDS. 

This is an accident so extremely rare, that it is not mentioned by 
many surgical authorities. The possibility of its occurrence is proved 
by a case which came under the observation of Mr. John Soden, Jun., 
of Bath, and also by a preparation, to which reference will be found in 
another page. An account of the case referred to was drawn up by 
Mr. Soden, and read before the Royal Medical and Chirurgical Society 
of London, and published in their Transactions for the year 1841. A 
description of the case will also be found with an engraving in Sir 
Astley Cooper's work on "Fractures and Dislocations," edited by Mr. 
Bransby B. Cooper. The following are some of the particulars. Jo- 
seph Cooper died in the Bath United Hospital in November, 1839, in 
consequence of a compound fracture of the skull, and his death afforded 
an opportunity of examining an old injury of the right shoulder, caused 
by receiving the whole weight of his body on his elbow in falling back- 
wards. After the subsidence of the inflammatory symptoms which super- 
vened, a difference was perceived between the two shoulders. When 
the man stood erect with his arms dependent, the bone appeared to be 
drawn too much up in the glenoid cavity. The power of abduction 
was very limited, because the humerus came against the acromion pro- 
cess ; and when the arm was moved, on placing the hand on the shoulder, 
a sensation of crepitus simulating fracture was experienced, which, how- 
ever, was merely the rubbing of the humerus on the acromion process. 
The head of the humerus appeared unnaturally prominent in front ; the 
man could move his arm backwards and forwards, but was unable to 
raise the smallest weight ; and any exertion or motion which could ex- 
cite the action of the biceps, caused severe pain, and could not, there- 
fore, be performed. The capsular ligament was but slightly ruptured, 



256 DISLOCATIONS OF THE ELBOW JOINT. 

but the tendon of the biceps was dislocated from its groove, and placed 
on the lesser tubercle of the humerus, — a position which accounted for 
the pain experienced where any force was used which called the biceps 

Fig. 68. 




muscle into action. The head of the humerus was sent upwards, and 
where it was in contact with the acromion process, ulceration had com- 
menced on the head of the humerus. This case shows how greatly the 
tendon of the biceps contributes to the strength of the joint, and how 
useful it is, when in its proper situation, for preventing dislocation upwards. 
In the museum of the Medico-Chirurgical Society of Aberdeen, there 
is a preparation of an unreduced partial dislocation upwards, which, in 
all respects, very closely agrees with the description and figure of the 
above case. It was taken from the body of a subject brought to one of 
the dissecting-rooms in Aberdeen. 

DISLOCATION OF THE ELBOW JOINT. 

This articulation is formed of three bones, the humerus, the ulna, and 
the radius. It is furnished with four proper ligaments, the anterior, 
posterior, external lateral, and internal lateral ; and it is liable to six 
dislocations ; of which three include both bones of the forearm, and 
three are dislocations of single bones. 
They are named thus — 

Dislocation of both bones backwards. 

Dislocation of both bones inwards. 

Dislocation of both bones outwards. 

Dislocation of the ulna backwards. 

Dislocation of the radius backwards, and 

Dislocation of the radius forwards. 

I. DISLOCATION OF BOTH BONES BACKWARDS. 

This is the most frequent of the dislocations at the elbow, and is 
caused sometimes by a wrench, but more generally by a fall on the 
hand, when the forearm is not perfectly extended. Under such cir- 
cumstances the radius and ulna come suddenly to a state of rest, and 
the humerus by the weight of the body is thrown forwards on them. 

Symptoms. — There is an unnatural prominence behind the joint 



DISLOCATIONS OF THE ELBOW JOINT. 



257 



caused by the extremities of both bones, but more especially of the ulna, 
and an unnatural hard swelling in front of the elbow produced by the 
extremity of the humerus. The anterior aspect of the forearm is pre- 
ternaturally shortened. In some cases, the forearm is at a right angle 
with the arm, while in others it is midway between extension and semi- 
flexion. The hand is between pronation and supination, but more in- 
clined to the latter. The motions of flexion and extension, as well as 
those of pronation and supination, are suspended, or at all events very 
difficult, limited, and painful ; but an unnatural lateral motion can be 
produced. The accompanying figure from Liston, represents an unre- 
duced dislocation of seven years' standing, in which case the movements 
of the hand were considerably regained. 

Fig. 69. 




Fig. 70. 



State of the Parts. — The coronoid process of the ulna occupies the 
olecranon fossa, the head of the radius is 
lodged behind the external condyle, and the 
lower end of the humerus rests on the an- 
terior surface of the radius and ulna. All 
the four ligaments are ruptured, though 
some of the fibres of the internal lateral are 
preserved. The triceps muscle is much re- 
laxed from the approximation of its points of 
attachment ; the brachialis anticus and the 
biceps are either very much put upon the 
stretch or lacerated, and. the former has been 
found occasionally to tear away a portion of 
its osseous attachment to the coronoid pro- 
cess. All the muscles originating from either 
condyle of the humerus, except the supina- 
tor radii brevis, are in a state of relaxation. 




Figs. 69 and 70. From Liston. 
17 



258 DISLOCATIONS OF THE ELBOW JOINT. 

Treatment. — Sir Astley Cooper recommends the surgeon, having 
seated his patient on a low chair, to place his knee in front of the elbow 
joint, against the front of the radius and ulna, and after having for 
some time attempted, by pressing backwards with his knee, to dislodge 
the coronoid process from the olecranon fossa, then forcibly but slowly 
to attempt flexion of the forearm, when reduction will be soon accom- 
plished. The object of pressing with the knee is, as already stated, to 
displace the coronoid process from the olecranon fossa; and the object 
of the forcible flexion is to bring the bones forward to their natural po- 
sition. Baron Boyer effected reduction in another manner. In accor- 
dance with his mode, an assistant is to take hold of the middle of the 
humerus, and thus afford the necessary counter-extension, and another 
assistant to make extension at the wrist, keeping the forearm at a right 
angle with the arm, while the surgeon grasps the elbow with both hands, 
having his fingers in front of the humerus, and his thumbs on the ole- 
cranon process, against which he directs pressure downwards and for- 
wards. According to Sir Astley Cooper's method, the surgeon endea- 
vours to displace the coronoid process from the olecranon fossa, by 
pressing the knee against the front of the forearm ; in Baron Boyer's, 
by pressing with the thumbs the olecranon process downwards and for- 
wards. In the former plan the bones are brought forward by flexion of 
the forearm ; in the latter, by an assistant pulling at the wrist. 

I have, with great ease and readiness, effected reduction by employing 
two assistants, — one for fixing the humerus, the other for effecting 
extension, which can be best done by grasping the middle of the fore- 
arm with both hands, and pulling forwards — and while extension and 
counter-extension are being used, by placing the fingers of one hand 
in front of the forearm, as near as possible to the elbow, and the other 
upon the olecranon process, and pulling forcibly with both hands, 
as if the object were to draw the heads of both bones of the forearm 
away from the humerus. By this means the coronoid process is very 
speedily dislodged from the olecranon fossa, and the extension then 
brings the bones forward to their natural situation. The advantage of 
affording extension, by grasping with both hands the middle of the fore- 
arm, is, that the force thus acts as much on the ulna as on the radius ; 
whereas, if extension be applied at the wrist, the force is in a great 
measure lost, for the ulna, which offers the chief obstacle to reduction, 
being small near the wrist, and having little connexion with that arti- 
culation, is acted upon only indirectly through the medium of the struc- 
tures by which it is connected with the radius. According to Mr. 
Liston, reduction is thus accomplished : — " The arm and forearm are 
extended, and the limb is brought well behind the trunk, so as to relax 
the triceps ; the surgeon performs extension and counter-extension, 
pulling the forearm with one hand, whilst he pushes with the other, 
placed on the scapula. If the force thus employed prove insufficient, 
as it seldom will in recent cases, the patient may be placed on his face 
on a couch, and on the limb being brought into the favourable position 
already noticed, counter-extension may be made by the heel planted 
against the inferior costa of the scapula, whilst the wrist is pulled with 
both hands." 



DISLOCATIONS OF THE ELBOW JOINT. 259 



The radius and ulna may be dislocated laterally, that is, they may be 
drawn to the one side of the humerus or the other ; but these disloca- 
tions are extremely rare, and never complete, on account of the great 
breadth of the articulating surfaces. They are readily detected by the 
unnatural prominence along the plane of the joint, either internally or 
externally, according to the nature of the dislocation, and by the in- 
ability to flex the forearm ; and they are easily reduced by fixing the 
arm, pulling the forearm, and pressing the bone, either outwards or in- 
wards, as the case may demand. 

IV. DISLOCATION OF THE ULNA BACKWARDS. 

The distinguishing marks of this dislocation are, the projection of 
the olecranon process behind the humerus, the hand and forearm being 
twisted inwards to the ulnar aspect of the forearm, and the impossibility 
of bending the forearm to more than a right angle. , In some instances 
it has been found impossible to bend it even to that extent, and any 
attempts to do so have caused excessive pain. In one recorded dissec- 
tion of this dislocation, the coronoid process was lodged in the olecranon 
fossa ; the coronary, oblique, and part of the interosseous ligaments, 
were torn ; the triceps muscle was much relaxed, and the brachialis mus- 
cle stretched under the humerus. 

Treatment. — Press the knee against the front of the elbow joint ; 
then with one hand attempt to bend the forearm over the knee, drawing 
it at the same time forwards, and with the other hand, the olecranon 
process downwards and forwards. In a case occurring in the practice 
of Mr. Gosset, in which the coronoid process rested on the internal con- 
dyle instead of the olecranon fossa, and the pain on bending the arm 
was insupportable, owing it was supposed to the pressure of the coro- 
noid process against the ulnar nerve, reduction was accomplished by 
extension and counter-extension applied by two persons pulling in oppo- 
site directions, and by the pressure of the olecranon process downwards 
and outwards, w T hile the forearm was suddenly flexed. 

V. DISLOCATION OF THE RADIUS BACKWARDS. 

This must be an extremely rare injury, since Baron Boyer has met 
with it only twice, and Sir Astley Cooper saw it only once in the dead 
subject, but never in the living body. Mr. Lawrence has seen the ac- 
cident, and Mr. Bransby B. Cooper gives a short description of one 
case complicated with fracture of the ulna, which came under his obser- 
vation ; but the most minute account I have seen of this dislocation is 
by Professor Lagenbeck, of Gottingen, who met with two examples, the 
one in a man twenty years of age, and the other in a child of five years. 
In these cases, which are published in "The Lancet," the hand was 
prone and could not be brought into a state of supination ; the forearm 
was moderately bent, and admitted of neither flexion nor extension ; the 
skin was lax along the inner side of the internal condyle, and the head 
of the radius could be felt behind the external condyle ; the articulating 
cavity of the head of the bone could be felt in the child, but its circum- 



260 DISLOCATIONS OF THE ELBOW JOINT. 

ference only in the adult. In both these cases, replacement was accom- 
plished by applying counter-extension to the arm, and extension to the 
forearm, and pressing the head of the bone inwards. Strong and long- 
continued extension was necessary in the one case, while very moderate 
extension with pressure was sufficient in the other. In this injury, ex- 
tension should be made from the hand, and when it has been employed 
for some time, and is still being continued, it would be judicious, be- 
sides pressing the head of the bone inwards, to supinate the hand for- 
cibly, which would assist the pressure in sending the head of the bone 
forwards, because in supination, while the under extremity is sent out- 
wards, the superior is directed forwards. In the example which Sir 
Astley Cooper met with in the dead subject, the account of the state of 
the parts on dissection is as follows : — The head of the radius was found 
behind the external condyle, the coronary and oblique ligaments were 
torn, and the capsular ligament — by which I suppose is meant part of 
the external lateral, and anterior ligaments, — had partly given way. 

[Dr. Gibson, of the University of Pennsylvania, states, in the first 
volume of his Surgery, that he has seen several cases of dislocation 
backwards of the head of the radius, and that he considers it more common 
than dislocation forwards. In 1826, he exhibited to the class " a case 
in which both radii were luxated at the same moment, from the patient 
being precipitated suddenly before a hogshead of sugar, whilst in the 
act of rolling it." — Ed.] 

VI. DISLOCATION FORWARDS OF THE RADIUS. 

Baron Boyer never met with this dislocation, and says, that no 
authentic example exists of the bone being thrown forwards on the exter- 
nal condyle. Many cases, however, are recorded : Sir Astley Cooper met 
with six examples ; Mr. Bransby B. Cooper with two ; and instances 
have occurred in the experience of Mr. Lawrence, Mr. Tyrrel, Mr. 
Gosset, and many other surgeons. I have met with two examples, the 
one in a girl of eleven, the other in a boy of about thirteen years of age : 
the symptoms were nearly the same in both cases. The forearm was 
about midway between complete extension and semiflexion, the hand 
slightly supinated, making an angle of about forty-five degrees with the 
plane of complete supination ; the movements in the direction of prona- 
tion and supination, as well as those of flexion and extension, were ex- 
tremely limited ; and on attempting to bend the forearm, I was particu- 
larly sensible of a sudden check to further flexion by an obstacle which 
left a decided impression of its being caused by one bone striking against 
another. There was a perceptible alteration of the direction of the long 
axis of the radius, which, instead of leading up to the under part of the 
external condyle, was directed in front of it, where the head of the 
radius could be distinctly felt, forming an unnatural tumour. There 
was an unnatural depression perceptible below the external condyle, and 
in one of the cases the patient complained of great pain in the upper 
part of the interosseous space, which pain was much aggravated by 
pressure. In each case, I accomplished reduction by making one 
assistant fix the humerus, and another effect extension from the hand, 
by which means the force acts on the radius alone ; and when extension 



DISLOCATIONS OF INFERIOR RADIO-ULNAR. 



261 



and counter-extension had been employed for some time, and were still 
being used, with the arm as straight as could be made, I then with the 
thumb of one hand forcibly pressed the head of the bone backwards, 
making at the same time with the other hand, a forcible attempt at pro- 
nation, when the head of the bone was tilted back into its proper situa- 



Fiff. 71. 



Fig- 72. 





tion. In one of the cases, reduction was accomplished with great diffi- 
culty, in consequence of its having remained for four days unreduced, 
during which the case was treated as a sprain by a practitioner, who 
mistook the nature of the injury. 

The head of the bone rests above the external condyle, and it is the 
resistance offered by the humerus which prevents flexion of the forearm. 
The external lateral, and anterior ligaments of the elbow-joint are lace- 
rated, as are also the coronary, the oblique, and part of the inter- 
osseous ; otherwise the radius could not get into its unnatural situa- 
tion. 

The two dislocations last described are as properly accounted disloca- 
tions of the superior radio-ulnar articulation, as of the elbow-joint, — 
both articulations being involved in the injuries. 

DISLOCATIONS OF THE INFERIOR RADIO-ULNAR ARTICULATION. 

These injuries, which consist of the displacement of the one bone 
with respect to the other at the inferior radio-ulnar articulation, are 



Fij 



From Listou. 



262 DISLOCATIONS OF INFERIOR RADIO-ULNAR. 

not to be confounded with dislocations of the wrist-joint. The writers, 
who have described these rare accidents, have not all employed the 
same nomenclature, some making the direction of the radius, others 
that of the ulna, the basis of arrangement. There are only two of these 
dislocations. They are described by some authors as dislocation for- 
wards and dislocation backwards of the radius ; by others, as dislocation 
backwards and dislocation forwards of the ulna. As the two bones are 
driven in opposite directions, it follows, that the dislocation forwards of 
the radius of some authors is the dislocation backwards of the ulna of 
others, and that dislocation backwards of the radius of some is the dis- 
location forwards of the radius of others. In the following description 
the direction of the radius is made the basis of arrangement. 

These dislocations are generally produced by the hand being carried 
too far round in the directions of pronation and supination ; and of the 
two, dislocation forwards is the more frequent, partly, because the 
motion of pronation is more extensive than that of supination, and 
partly, because violent and immoderate force, which is often required 
in efforts accompanied with pronation, can seldom be necessary in any 
offices which the hand has to perform in a state of supination. Desault 
records the case of a laundress who, by a violent pronation of her hand 
in wringing a wet sheet, produced dislocation forwards of the radius. 
The dislocation backwards of the radius has not in every case been 
caused by supination. Dupuytren mentions the occurrence of an ex- 
ample in one of the gendarmerie, where the injury was occasioned by 
his horse falling, and his forearm being crushed between the horse's 
head and the ground. The dislocation forwards seldom occurs ; and 
the dislocation backwards is so extremely rare, that in a long experience 
Desault never met with it in the living body, and only once in the dead 
subject ; Dupuytren saw but two cases, Boyer but one ; and Sir Astley 
Cooper has not recorded a single example. 

In dislocation forwards the forearm is bent, the hand being carried 
beyond the natural extent of pronation ; there is an unnatural promi- 
nence at the posterior and inner part of the wrist, caused by the ulna ; 
and the motions of pronation and supination are suspended. Replace- 
ment is easily accomplished in the following manner : — The arm is fixed 
by an assistant, and the surgeon, with the fingers and thumb of one 
hand, separates the bones from each other, pressing the one backwards 
and the other forwards, and with the other hand, he at the same time 
forcibly turns the hand into a state of supination ; by which movement 
the radius is sent back to its proper position. The injury is caused by 
violent pronation : it is reduced by forcible supination. 

In dislocation backwards the hand is carried beyond the natural ex- 
tent of supination ; the motions of pronation and supination are sus- 
pended ; the natural prominence formed by the ulna at the back of the 
wrist disappears ; and an unnatural projection in front of the wrist is 
caused by the under part of the ulna. In the example of the officer, 
whose case is recorded by Dupuytren, and where violent supination was 
not the cause of the injury, the hand was not supinated, but midway 
between pronation and supination. The direction of the ulna was too 
far forward, the lower extremity coming in front of the radius ; there 



DISLOCATIONS OF THE WRIST JOINT. 263 

was an unnatural depression at the back, and an unusual prominence in 
front of the wrist. Replacement may be accomplished by fixing the 
arm, and with one hand separating the bones from each other, pressing 
the one backwards and the other forwards, and with the other hand 
forcibly producing pronation ; by which means the hand, and with it 
the radius, is carried forward. The dislocation may be caused by supi- 
nation being carried to too great an extent, and it may be reduced by 
forcible pronation. 

Violent pronation may cause dislocation backward of the upper, and 
forward of the under extremity of the radius ; and forcible supination is 
a principal means of reducing these dislocations. 

Supination carried beyond the proper extent may induce dislocation 
forward of the upper, and backward of the under extremity of the 
radius ; and forcible pronation is of the greatest consequence in reduc- 
ing these dislocations. 



This articulation is formed above, by the radius and triangular fibro- 
cartilage, and below, by the first three bones of the carpus, namely, the 
scaphoid, semilunar, and cuneiform bones. It is furnished with four 
ligaments, and is liable to five dislocations. Both bones of the forearm 
may be thrown forwards, backwards, inwards, or outwards, and the 
radius alone may be driven forwards on the front of the carpus. The 
dislocations forwards and backwards are exceedingly rare, especially 
the former. The celebrated Dupuytren went even so far as to say, 
" that there was not a single unequivocal instance on record of a dislo- 
cation of the radio-carpal articulation, and that he invariably found 
these pretended accidents always turned out to be fractures of the 
radius near the articulation." It is now, however, quite certain that 
these dislocations, though rare, do occasionally take place. 

I. DISLOCATION FORWARDS. 

The dislocation forwards is produced by a fall on the palm of the 
hand during extension, and may be detected by a swelling on the fore 
part of the wrist, produced by the radius and ulna, and another on the 
back part, caused by the carpus ; by an unnatural depression above the 
last-mentioned swelling ; by the styloid processes of the radius and ulna 
not presenting their natural relation to the carpus, and by the hand 
being extended and fixed. 

II. DISLOCATION BACKWARDS. 

The dislocation backwards usually occurs from a fall on the back of 
the hand, while the hand is fixed. It is characterized by two unnatural 
swellings, — one on the back of the wrist, caused by the radius and ulna, 
the other in front, caused by the carpus ; and by the hand being vio- 
lently bent and fixed. 

These dislocations may be distinguished from sprains by the existence 
of two swellings ; whereas in sprains there is only one; and that does 
not appear immediately, but, when it does, gradually increases. For 
distinguishing between dislocation of the wrist, and fracture of the radius 



264 DISLOCATIONS OF THE THUMB. 

near the wrist, when the inflammatory swelling renders it difficult to 
detect the real nature of the case, it is of importance to take hold of 
the hand, and move it, observing at the same time whether or not the 
styloid processes of the radius and ulna be movable. If the injury be 
a fracture, they will change their position ; but if it be a dislocation, they 
will remain fixed. 

III., IV. LATERAL DISLOCATIONS. 

The lateral dislocations are never complete, on account of the breadth 
of the articulating surfaces ; in consequence of which some part of the 
under portion of the articulation still rests against some part of the 
upper. • A projection of the carpus on the one side of the wrist, and of the 
radius or ulna on the other, with a fixed condition of the hand, are 
symptoms sufficiently diagnostic to make these injuries easy of detection. 
The deformity of parts is so distinct, that there can be no difficulty in 
recognising these accidents, and their replacement is equally easy by 
the following means. 

While the forearm is held firmly by an assistant, so as to afford the 
necessary counter-extension, and another assistant makes extension from 
the hand, the surgeon should press the displaced bones towards their 
proper situation. When extension and counter-extension have been 
used to a sufficient degree to prevent the bones from pressing against 
each other, the contraction of the muscles will powerfully aid in accom- 
plishing reduction. After reduction, antiphlogistic remedies, of rather a 
smart character, are frequently necessary to subdue the very considerable 
tumefaction and inflammation which sometimes result from the injury 
to the soft parts ; and recourse must be had to the cautious use of a 
splint, to prevent any motion of the hand which would be apt to cause 
a recurrence of the dislocation, and hinder the union of the ligaments ; 
but care must be taken so to apply it, as not to produce any pressure, 
which would aggravate the local inflammation, if it should supervene. 

V. DISLOCATION FORWARDS OF THE RADIUS ALONE, ON THE FORE PART 

OF THE CARPUS. 

This is quite a different dislocation from that of the radius forwards 
at the inferior radio-ulnar articulation. In this dislocation the styloid 
process is no longer in a line with the radial side of the carpus ; the 
under extremity of the radius forms a protuberance on the front of the 
carpus ; the hand is fixed, and its outer border is twisted backwards, 
and its inner forwards. These symptoms are sufficiently diagnostic of 
the nature of this injury, the reduction and after-treatment of which are 
the same as when both bones are displaced. 

DISLOCATIONS OF THE THUMB. 

The first metacarpal bone of some anatomists, the first phalanx of 
the thumb of others, is capable of being dislocated in four directions, 
namely, inwards, outwards, forwards, or backwards; but, in general, 
it is dislocated only forwards or backwards. Mr. Lawrence is of 
opinion that a dislocation backwards is the only dislocation of this 
bone that can take place. In many cases seen by Sir A. Cooper, the 
metacarpal bone was thrown inwards, between the os trapezium and the 



DISLOCATIONS OF THE THUMB. 265 

metacarpal bone of the fore-finger, so as to form a protuberance 
towards the palm of the hand. The thumb was bent backwards and 
did not admit of being brought towards the little finger. The unnatural 
protuberance, formed by the articular end of the bone, is so very con- 
spicuous, that the nature of the accident is immediately recognised. 
Much pain and swelling are produced by the accident. For facilitating 
reduction, Sir A. Cooper advises extension to be made with the thumb 
inclined towards the palm, in order to relax and diminish the resistance 
offered by the flexor muscles. After steady extension for a considerable 
time, the bone should be forced into its place by making pressure with 
the fingers on the head of the bone. When reduction is impracticable, 
Sir Astley deems it preferable to leave the case to the degree of recovery 
which nature will in time produce, rather than run any risk of injuring 
the nerves and blood-vessels by dividing the muscles or ligaments. 

Dislocation of the first Phalanx. — A more frequent, and at the same 
time more troublesome dislocation, because of the difficulty of its reduc- 
tion, is the dislocation of the first phalanx from the metacarpal bone. 
The deformity of the parts reveals the nature of 'the injury. The 
extremity of the first phalanx forms a prominence on the back of the 
head of the metacarpal bone, and the lower part of the metacarpal bone 
is equally perceptible on the palmar side. In reducing it, which it is 
comparatively easy to accomplish in the recent state, the thumb should 
be inclined towards the palm ; and during straight extension of the 
thumb, pressure should be made with the finger on the head of the 
extremity of the first phalanx. But after a little time has elapsed, there 
is often very great difficulty in effecting reduction, — so much so, that 
Sir A. Cooper considered dislocations of the thumb as the most difficult 
to reduce. " In order to relax the parts as much as possible, the hand 
should be soaked for a considerable time 
in warm water ; a piece of wetted wash- Fi S- 73 - 

leather is to be as closely wrapped round 
the first phalanx as possible ; a tape, 
about two yards in length, should be 
fastened on the leather with a knot 
that will not slip, such as the sailors call 
the clove-hitch. An assistant should now 
firmly press on the metacarpal bone, by 
putting his middle and first fingers be- 
tween the fore-finger and thumb of the 
patient, and thus make a counter-exten- 
sion, whilst the surgeon, assisted by 
others, draws the first phalanx from the 
metacarpal bone, inclining it at the same time a little towards the palm 
of the hand. If the efforts made in this way, after having been con- 
tinued ten or fifteen minutes, should not succeed, then it will be 
necessary to adopt another plan, which is this, — in addition to the 
apparatus already employed, let a strong worsted tape be carried 
between the metacarpal bone and fore-finger, bend the forearm round 
a bed post, and let the tape be firmly tied to it, so as to prevent the 




266 DISLOCATIONS OF THE HIP JOINT. 

hand yielding when extension is made. To the tape surrounding the 
first phalanx a pulley is to be applied, and extension made, which will 
generally succeed." — Sir A. Cooper, Lectures on Surgery, pp. 638, 
639. 

The proposal has been suggested of dividing one of the lateral liga- 
ments with a couching needle, or a very small knife, when reduction 
is impossible by ordinary means. The best authorities, in general, 
unite in condemning this practice on account of the frequency with 
which tetanus is induced by injuries of tendons and ligaments connected 
with the thumb. Mr. Syme, however, says: — "In cases where the 
difficulty proves insuperable, one of the lateral ligaments may be cut, 
which would certainly be better than leaving the bone unreduced, as 
has sometimes been the case." 

Sometimes the dislocation takes place in the other direction, the 
metacarpal bone being forced behind the extremity of the first phalanx. 
Here there is less difficulty in accomplishing reduction. 

The phalanges of the fingers are sometimes dislocated backwards. 
The accident cannot be mistaken, and reduction by means of extension 
is accomplished with facility. 

DISLOCATIONS OF THE HIP JOINT. 

The ilio-femoral articulation, or hip joint, is formed by the cotyloid 
cavity of the os innominatum, and the head of the femur. It is fur- 
nished with a large synovial membrane, and five ligaments, namely, the 
capsular, the accessory, the cotyloid, the transverse, and the ligamen- 
tum teres or round ligament. The direction in which the ball of the 
femur is sent from the acetabulum is the basis of arrangement of its 
different dislocations. 

It will facilitate the description of the various dislocations of the hip 
joint to arrange them in two grand classes, the regular, and the anoma- 
lous. Of the former class there are four different kinds, and the same 
number of the latter class have been recorded. 

REGULAR DISLOCATIONS OF THE HIP JOINT. 

The head of the thigh bone may be thrown from the acetabulum in 
the four following directions, constituting, the four regular dislocations: — 

1. Upwards, upon the dorsum of the ilium. 

2. Backwards, into the ischiatic notch. 

3. Downwards and forwards, into the foramen ovale. 

4. Forwards, upon the pubes. 

With regard to the proportionate frequency of these several disloca- 
tions, Sir Astley Cooper says, that in twenty cases, you may have 
twelve of the first kind, five of the second, two of the third, and one of 
the fourth. 

I. DISLOCATION UPWARDS ON THE DORSUM OF THE ILIUM. 

Symptoms. — When the bone has been displaced in this direction, the 
dislocated limb is more or less shortened. This symptom appears im- 



DISLOCATIONS OF THE HIP JOINT. 



267 



Fig. 74. 



mediately, but, after the muscles have had time to contract, it increases so 
much, that the point of the great toe 
of the affected side does not extend 
beyond the tarsus of the other foot. 
The shortening will be best seen by 
supporting the patient in the erect 
posture, and comparing the position 
of the toes, or of the inner ankles. 
The thigh, leg, and foot are all in- 
verted, so that the great toe of the dis- 
located extremity rests on the tarsus 
of the opposite foot. The knee is 
very slightly bent, and a little in 
advance of the under part of the 
other thigh. The limb is perfectly 
immovable to the voluntary efforts of 
the patient, nor can it be moved by 
the surgeon in the direction of abduc- 
tion or of extension ; and if it can be 
slightly moved in the direction of ad- 
duction or of flexion, such movements 
are attended with great pain. There 
is an unnatural swelling of the hip, 
caused by the upper part of the femur, 
and the bulging out of the glutei mus- 
cles. If the patient be thin, and the 
bone be not concealed by extravasa- 
tion of blood and the general tume- 
faction of the hip, which may soon 
follow such an injury, the head of the 
femur may be distinguished on the os 
innominatum, with its ball directed 
backwards, and its trochanter major 
forwards, and much nearer than natu- 
ral to the anterior superior spinous process of the ilium. Another symp- 
tom is, the absence of the natural projection of the trochanter major. 
The distinctive marks of this injury are so unequivocal that an attentive 
observer can be at no loss to recognise it. They may be stated briefly 
to be, — Shortening of the extremity; inversion; the knee slightly bent, 
and a little in advance ; the limb immovable to the voluntary efforts of 
the patient, and to the surgeon in the direction of extension or abduction ; 
absence of the natural projection of the trochanter ; an unnatural swell- 
ing of the hip ; and the trochanter major raised upwards and forwards, 
so as to be too near to the anterior superior spinous process of the ilium. 
State of the Parts. — The capsular, accessory, and round ligaments 
must be ruptured, and the muscles torn up from the dorsum ilii, before 
the bone can occupy its unnatural situation. The upper extremity of 
the femur rests on the dorsum ilii, the ball being directed backwards, 
and the trochanter forwards. It has often been a subject of inquiry, 
why the ball is always directed backwards, and the trochanter forwards, 
and why it is not thrown into the attitude in which the principal muscles 




268 



DISLOCATIONS OF THE HIP JOINT. 



of the limb would place it. In France, the explanation proposed by 
Baron Boyer is considered satisfactory. He ascribes it to the strong 
anterior portion of capsular ligament, which proceeds from the upper 
and anterior part of the acetabulum to the anterior intertrochanteric 
line. When the bone is driven upwards, these fibres draw the trochan- 
ter towards the acetabulum, and prevent the bone from being twisted 
outwards as the rotators would direct it. 

Treatment. — It is not advisable to attempt reduction, without having 
previously weakened the muscular power. The means formerly em- 
ployed for that purpose consisted of copious bleeding, followed by a dose 
of antimony, or small doses of half a grain every ten minutes until 
nausea was produced. Or, when it could conveniently be done, the 
patient was first bled, then placed in a warm bath, and afterwards got 
doses of antimony until nausea came on, when the muscles were less 
able to resist reduction. The patient was, in all probability, much less 
injured by these debilitating remedies, than by the much greater exten- 
sion which would otherwise have been necessary. Instead of any of the 
above-mentioned proceedings, the auxiliary now employed is chloroform, 
which not only has the advantage of being more powerful, but also of 
preventing pain, and has, besides, no permanently weakening effect on 
the system. An assistant being in readiness with a set of pulleys, the 
patient should be placed on his back or opposite side on a table of con- 
venient height, particular care being taken that he be in such a position 
as to have the long axis of the thigh-bone in a straight line between 
two rings or staples fixed in some resisting objects in opposite sides of 
the room. To afford the necessary counter-extension to the pelvis, 
a strong well-padded leather belt or girth should be passed round the 
limb, so as to press on the side of the perineum (to prevent the chafing 
of which the padding is necessary), having its extremities directed out- 
wards and upwards, so as to be in a line with the long axis of the thigh- 
Fig. 75. 




bone, and fixed to one of the staples or rings before-mentioned. For 
affording the necessary extension, a few turns of a wetted linen roller 
should be tightly applied to the thigh, above the knee, over which 
should be very firmly buckled a leather belt furnished with two straps 
at right angles to itself, each having a ring at its extremity. The 
one set of pulleys should be fixed to the rings, and the thigh being 



DISLOCATIONS OF THE HIP JOINT. 



269 



directed a little forwards across the under third of the opposite 
thigh, and the leg of the affected side bent nearly to a right angle, the 
other set of pulleys should be fixed to the other ring or staple in the 
room. The direction of the axis of the thigh being carefully preserved 
in a straight line with the extending and counter-extending forces, the 
extension is to be applied by the surgeon himself, or by an assistant 
under his direction, by drawing the cord of the pulleys. The manner 
of doing this is, however, of the greatest importance ; it ought not to be 
done suddenly, or violently, but slowly, steadily, and gradually ; the 
cord should be drawn until considerable extension be produced, when 
the force should not *be increased, but steadily kept up ; and when the 
muscles have had time to stretch, it should then be increased ; and after 
another interval, during which the same degree of extension is preserved, 
the force should be again increased. When the ball of the femur is 
brought near to the acetabulum, it will be necessary for the surgeon to 
employ an assistant to keep up the extension ; while he himself, taking 
hold of the femur, endeavours with one hand to raise ,the head of the 
bone from the ilium, by pressing upwards with the hand placed under 
the thigh, — the object being to diminish the resistance offered by the 
margin of the acetabulum to the ball of the bone gliding over it ; and 
with the other hand he endeavours to rotate the thigh outwards for the 
purpose of inclining the trochanter backwards and the ball of the bone 
downwards and forwards. The advantage of attempting rotation must 
be evident from what has been stated regarding the position of the bone 
in this dislocation. The bone seldom returns with a snap when the 
pulleys are employed, from the muscles being so much w r orn out that 
they are not able to exert that sudden and powerful contraction which 
commonly accompanies reduction of a dislocation. The surgeon must, 
therefore, determine by the absence of the symptoms of dislocation that 
the reduction has been accomplished. 

Fig. 76. 




The above are the best appliances for the application of the extending 
and counter-extending forces : but if they cannot be obtained, a sheet 



270 



DISLOCATIONS OF THE HIP JOINT. 



or tablecloth, with a quantity of tow or linen placed so as to diminish 
the danger of chafing, may be used for the latter purpose, and a skein 
of worsted, to which the pulleys may be fixed, for the former. 

[The extension may be effected in a very simple manner, by the con- 
trivance of Dr. Gilbert, already described in the first part of the chapter 
on Dislocation. As will be seen in the wood-cut (Fig. 76), the patient 
is placed as is usual, and the counter-extension is made in the ordinary 
way : but the extension is made by twisting by means of a strong stick, 
a rope which had been twice doubled, and the extremities of which had 
been properly secured to the limb and to a staple. — Ed.] 

II. DISLOCATION BACKWARDS INTO THE ISCHIATIC NOTCH. 

Symptoms. — In this, as in the last dislocation, we have shortening, 
inversion, an advanced position of the knee, and a fixed condition of 

the limb ; but the three 



Fig. 77. 




first mentioned symp- 
toms are to a less extent 
than in the former case. 
The shortening and in- 
version are such, that 
the point of the great 
toe rests upon the ball of 
the great toe of the op- 
posite foot, instead of 
upon the tarsus. The 
knee is less advanced, 
and is slightly bent : 
and when the patient 
is placed in the erect at- 
titude, the toes only 
touch the ground. — 
There is an unnatural 
projection on the back 
part of the hip ; the tro- 
chanter major is too far 
forward; and the natu- 
ral projection formed by 
it is lost. 

State of the Parts. — 
The capsular, accessory, 
and round ligaments are 
ruptured, and the head 
of the femur rests on 
the pyriformis muscle, 
above the sacro-sciatic 
ligaments and at the 
edge of the notch, with 
its ball directed back- 
wards and the trochan- 
ter forwards. 



DISLOCATIONS OF THE HIP JOINT. 



271 



Treatment. — Reduction is exceedingly difficult, but it is to be effected 
in the same manner, as in the former dislocation, with the following 
peculiarities, which require careful attention. The direction of the ex- 
Fig. 78. 




tending force should be across the middle, instead of across the under 
third, of the opposite thigh ; and as the extending and counter-extend- 
ing forces must always be in a line with each other, the direction of the 
mechanism for fixing the pelvis, although upwards and backwards, 
should be more directed backwards than in the reduction of the former 
injury. The sciatic notch, where the ball of the bone rests, is posterior 
to the acetabulum, and from the oblique position of the pelvis in the 
human body, a little higher up ; and as the object of extension is to 
draw the ball forwards and a little downwards, the reason of the pecu- 
liarity in the direction of the traction must be obvious. While exten- 
sion is being made, which ought to be done with the patient placed on 
his opposite side, the ball of the thigh bone should be raised out of 
the ischiatic notch, and over the edge of the acetabulum. With this 
view some recommend that a round towel be placed under the upper part 
of the thigh and over the shoulders of an assistant, who at the same 
time resting both his hands on the patient's pelvis, obtains a great power 
over the dislocated bone. 

As a symptom, the knee is less advanced than in the former disloca- 
tion ; but in reduction, it requires to be raised further forward, and 
crossed over the other thigh, higher up than is necessary, or proper, in 
replacing the bone in dislocation upwards. 



272 



DISLOCATIONS OF THE HIP JOINT, 



Fig. 79. 



III. DISLOCATION DOWNWARDS AND FORWARDS INTO THE FORAMEN 

OVALE. 

This dislocation has been known to occur in consequence of a fall 
from a horse, with the thigh under the body of the animal. It has also 
been sometimes occasioned by the fall of a heavy weight on the thigh, 
while the limbs were separated. I once saw an instance of this disloca- 
tion caused by the person jumping in great haste out of bed, and while 
the left foot reached the floor, the right was entangled by the blankets 
in bed, and in consequence, the ball of the femur was driven against the 
anterior and under aspect of the joint, thus occasioning a dislocation 
downwards and inwards. 

Symptoins. — The limb is elongated and violently abducted, nor can 
it without great pain and difficulty be brought near to the other limb. 

If the patient be raised to the erect 
attitude, he leans to the affected 
side ; or, if the trunk be kept per- 
fectly erect, the knee is very much 
in advance ; the rationale of which 
is, that the psoas magnus, and iliacus 
internus, are put very much on the 
stretch, and the patient endeavours 
to diminish the painful tension, by 
inclining the trunk to the affected 
side, or, if that be prevented, by 
bringing the thigh forward. The 
toes usually are neither inverted nor 
everted ; the trochanter major is less 
prominent than usual, and there is 
an unnatural hollow below Poupart's 
ligament. 

State of the Parts. — The ball of 
the femur is in front of the foramen 
ovale, resting on the obturator ex- 
ternus muscle ; and it is important 
to observe that the ball is directed 
inwards, and the trochanter major 
outwards. There is rupture of two 
of the five ligaments of the hip joint, 
namely, the capsular, and the round. 
On this last point, however, — the 
rupture of the round ligament, a dif- 
ference of opinion exists. Sir Astley 
Cooper believed that in every in- 
stance it must be ruptured, and re- 
cords a dissection of a dislocation in 
which he found it so, whereas the 
celebrated Delpech, although he admits that it is sometimes ruptured, 
asserts that this is not always the case, and relates some cases in which 
he found it unbroken. Some found their opinion, that the ligamentum 




DISLOCATIONS OF THE HIP JOINT. 



273 



teres is not necessarily ruptured, on the fact, that in the dead body, the 
ball can be placed on the front of the foramen ovale, without rupture 
of the ligament. I have often in the dead body, after removing all the 
muscles, and cutting the capsular ligament, placed the ball of the femur 
in this situation ; but it can only be done with the trochanter directed 
inwards and the ball outwards, in short, by turning backwards the part 
of the femur which is naturally directed forwards, and leaving the part 
of the ball to which the round ligament is attached, very near to the 
margin of the acetabulum. This, however, is not the position of the 
femur in the dislocation ; on the contrary, the ball is directed down- 
wards and inwards, and it will be found impossible in the dead subject, 
to place it in that position without first cutting through the round liga- 
ment. As has already been stated, Sir Astley Cooper is of opinion, 
that the round ligament is always ruptured ; and that the accident 
cannot occur to a living person, except when the limb is in a state of 
abduction, in which position the ligamentum teres is upon the stretch, 
and therefore if the force applied go so far as to dislopate the joint, the 
ligamentum teres must first give way. 

Treatment. — The ball of the femur is too low down, and too near the 
mesial plane. It may be reduced in one or other of the four following 
ways. 

Fig. 80. 




1st. The patient is laid on a table on his uninjured side. The pelvis 
is fixed by a belt pjaced round it, and secured to the tab*le. Extension 
is made by another belt placed under the thigh, the edge of which touches 
the perineum, and pulleys are attached directly above the patient. It 
is necessary for the surgeon to press down the ankle of the affected 
side. 

18 



274 



DISLOCATIONS OF THE HIP JOINT. 



Fig. 81. 



2d. Place the patient on his back. Counter-extension is made by a 
belt or girth, placed round the pelvis, the concavity of the belt being 
in contact with the injured side, and secured to a staple or some resist- 
ing object. The extending force is directed upwards and outwards. 
After extension has been continued for some time, the surgeon should 
pass his hand behind the ankle of the sound limb, and grasping the other 
ankle, should draw it inwards, towards or beyond the mesial plane of 
the patient's body. While this is being done, the belt in the perineum 
acts as a fulcrum, the femur as a lever, and the hand as the power ; 

and by bringing the under part of 
the femur inwards, and a little back- 
wards, the ball is sent upwards and 
outwards. This is Sir Astley 
Cooper's method. (See Fig. 80.) 

3d. Mr. Hey, of Leeds, reduced 
this dislocation in the following 
manner. He desired the patient to 
sit upon the front of the bed, astride 
of the bed-post, and to grasp it ; he 
then fixed two towels to the injured 
limb, and two assistants made exten- 
sion. While the extension was con- 
tinued, he crossed the injured thigh 
over the sound one, and at the same 
time rotated the limb. 

4th. Mr. Hey, in another case, 
flexed the thigh to such an extent 
as to form an acute angle with the 
trunk, and then by a rotatory motion 
of the thigh effected reduction. 




IV. DISLOCATION FORWARDS UPON 
THE PUBES. 



Symptoms. — The limb is shortened? 
usually to the extent of an inch- 
The knee and foot are turned out- 
wards, and the knee is drawn for- 
wards and away from the other. The 
limb cannot be moved at all by the 
voluntary efforts of the patient, and 
but very slightly by the surgeon ; 
nor can it be rotated inwards, al- 
though it may be pressed a little 
forwards and backwards. The head 
of the thigh-bone may be distinctly 
felt in the groin, giving rise to an 
unusual protuberance. The round- 
ness of the hip is lost in consequence of the trochanter major being 
drawn too near the mesial line, and the space between the trochanter 



DISLOCATIONS OF THE HIP JOINT. 275 

major and the anterior superior spinous process is diminished. There 
is frequently numbness or pain, from pressure on the anterior crural 
nerve. From these symptoms, compared with what has been stated as 
to the symptoms in fracture of the neck of the thighbone, the diagnosis 
may be easily made out. 

State of the Parts. — The ball of the femur rests on the anterior part 
of the pubes, with the trochanter directed backwards. The ball is on 
the horizontal part of the pubes, superior to the obturator foramen. In 
some cases it is sent up so high as to be hooked into the pelvis. The 
capsular and round ligaments must be ruptured, and the accessory may 
be injured. In a dissection mentioned by Sir Astley Cooper, the head 
and neck of the femur were driven under the psoas magnus and iliacus 
internus muscles, which, together with the anterior crural nerve, were 
thus put much upon the stretch on their way downwards. In a practical 
point of view, it is of great importance to remember that the trochanter 

Fig. 82. 




is directed backwards, and the ball forwards, — this being the very 
reverse of the position of these parts in the dislocations upwards and 
backwards. 

Treatment. — The knee should be pressed a little downwards. The 
counter-extension should be made over the trunk of the patient, and 
the extension in a line with it, so as to draw the thigh downwards and 
backwards. While extension and counter-extension are being employed 
a towel should be placed under the upper part of the thigh, and an 
assistant should lift up the head of the bone over the pubes and the 
edge of the acetabulum, the surgeon at the same time endeavouring to 
send the ball backwards by effecting rotation inwards of the thigh. 

ANOMALOUS DISLOCATIONS OF THE HIP JOINT. 

The following anomalous dislocations are recorded : — 
1. Dislocation upwards, with the ball below the anterior superior 
spinous process of the ilium, the neck against the ridge between the 
anterior superior and anterior inferior spinous processes, and the tro- 
chanter directed backwards. An instance of this dislocation occurred 



276 DISLOCATIONS OF THE HIP JOINT. 

in the experience of Mr. Gibson of New Lanark, and was successfully 
treated by him and Dr. Cummins. 

The symptoms were the following: — the limb was shortened fully 
three inches, and so fixed that it could not be lengthened in any degree ; 
the limb and toes were everted, rotation inwards was impossible, and 
any attempt to effect it caused great pain ; adduction and abduction 
were exceedingly painful and difficult, but very limited flexion could be 
performed with less pain. There was a tumour under the anterior 
superior spinous process, obedient to the motions communicated to the 
thigh, the trochanter major could not be felt, and the hip was flattened. 
The position of the bone was believed to be that which is here described ; 
and, for the accomplishment of reduction, nausea was induced by means 
of tartar emetic ; and then, while counter-extension and extension were 
being made by means of pulleys, Mr. Gibson raised the thigh-bone, by 
means of a round towel placed under the thigh and over his own shoul- 
ders, at the same time pressing the knee towards the opposite thigh, 
and forcibly rotating it inward. 

2. Dislocation upwards, with the ball between the anterior inferior 
spinous process and the junction of the ilium and pubes, the trochanter 
being directed backwards. 

A case of this dislocation is recorded by Mr. Morgan in Guy's Hos- 
pital Reports. The following were the symptoms : — shortening of the 
limb to the extent of two inches, extreme eversion of the foot, and a 
tendency on the part of the injured limb, when left to itself, to cross 
the sound one, the heel of the former resting on the instep of the latter. 
The ball of the bone could be discovered under Poupart's ligament ; the 
trochanter could not be felt ; and the limb could be moved to a certain 
extent in any direction except rotation. 

The bone was believed to be in the position above described. Mr. 
Morgan accomplished reduction by counter-extension and extension with- 
out pulleys, employing at the same time forcible rotation inwards of the 
limb. In order to obtain a greater power in effecting rotation, Mr. 
Morgan bent the leg at a right angle to the thigh, and rotated the thigh 
by holding the knee with one hand, and the foot with the other. 

3. Dislocation downwards on the tuberosity of the ischium with ever- 
sion of the foot. 

Mr. Keate was called to attend a gentleman who had suffered this 
dislocation by his horse falling backwards upon him into a narrow ditch, 
in which position he remained for some time, with his heels directed 
upwards and the horse's back next to his thigh. 

The limb was elongated more than three inches ; the leg was bent on 
the thigh, and the thigh bent*on the pelvis ; the thigh was carried very far 
away from the other, the knee and foot were much everted, and the tro- 
chanter exceedingly depressed. The ball of the bone was on a level 
with the tuberosity of the ischium, and it was believed that it had been 
brought into this situation by the struggling to get released from under 
the animal, after it had first been dislocated in front of the foramen 
ovale. In short, it was supposed that it had been first sent in front of 
the foramen ovale, and afterwards from thence to the tuberosity of the 



DISLOCATIONS OF THE KNEE JOINT. 277 

ischium ; and, therefore, in accomplishing reduction it was first brought 
from the tuberosity of the ischium to the front of the foramen ovale, 
and afterwards from thence to the acetabulum. 

4. Dislocation of the ball on the tuberosity of the ischium, with 
shortening of the limb, and violent inversion of the foot. 

A maniac became the subject of this dislocation, in consequence of 
leaping from a window in a third story. In falling, his thigh struck 
against the railing, and was violently driven upwards. He died in 
about an hour, and as he was evidently sinking from other injuries, the 
dislocation was not reduced. The limb was shortened and inverted; 
the thigh was bent and immovable, crossing the pubes obliquely to the 
opposite side. On dissection, the head of the femur was found to be 
above the quadratus fern oris muscle, and opposite to the upper part of 
the tuberosity of the ischium. The ramus of the ischium and the ilio- 
pubic symphysis were fractured, in consequence of which the injury 
cannot strictly be considered a simple case of a new anomalous dislo- 
cation. 

The ball of the femur has been found in some other situations than 
those mentioned above ; but so far as my reading extends, in almost all 
such recorded cases, other injuries, such as fractures, have accompanied 
the displacement, so that these cases cannot properly be considered as 
examples of new dislocations, but rather as showing how the combina- 
tion of other injuries with dislocation may affect the position of the 
bone. 

* 

DISLOCATIONS OF THE PATELLA. 

The patella is liable to three dislocations, two of them common, and 
the third, of which there are some varieties, extremely rare, and difficult 
of reduction. The common dislocations are inwards and outwards, the 
latter being much the more frequent. They may be complete or partial. 
In the third dislocation, the bone undergoes a semi-revolution on its 
long axis, so that only one of its edges is in contact with the femur. 

Each lateral dislocation may be the consequence of direct violence, 
but the dislocation outwards is often occasioned by muscular contraction. 
See causes of dislocations in the section on Dislocations in general. 

Symptoms. — The knee is immovable to both the patient and the sur- 
geon ; there is an unnatural depression in front of the joint, and an un- 
usual swelling on the inner or outer side of the femur, according to the 
direction of the dislocation. 

Treatment. — Reduction is effected by raising the trunk to the erect 
posture, elevating the leg so as to relax the rectus and triceps muscles, 
and then pressing the patella inwards or outwards according to the 
nature of the injury. Dislocation outwards has sometimes been reduced 
by elevating the limb and producing forcible flexion of the knee-joint. 

The dislocation' in which the patella makes a semi-revolution on its 
own axis, so as to have one of its margins in contact with the femur 
and the other with the integument, is so very rare that, as far as I know, 
there are only three cases recorded. 

One case, that of a private of the 2d Life Guards, was successfully 



278 DISLOCATIONS OP THE KNEE JOINT. 

treated by Mr. Mayo and Mr. Broughton. The injury was caused by 
a stroke on the right knee from the knee of another soldier, as the two 
opposite lines rode through each other. One edge of the patella rested 
on the outer surface of the external condyle, the other was directed out- 
wards, and the fore part of the patella was directed forwards and in- 
wards. Various methods were tried without success to effect reduction, 
which was at length accomplished by suddenly bending the knee so as 
to carry the heel back to the hip, when the patella returned to its proper 
situation. 

In this case, one edge of the bone was in contact with the outer part 
of the external condyle ; but in each of the other two cases, the one 
edge was in contact with the trochanter of the femur, and the other 
directed forwards. Of these two cases, one occurred in the experience 
of Mr. Welling, surgeon, at Hastings, and in that instance the integu- 
ments were very much elevated in front of the joint by one edge of the 
bone, the other edge resting against the femur. Replacement was 
effected by pressing the edges in opposite directions while the leg was 
extended. 

The other case is published in a German journal, " Rust's Magazin," 
and is quoted in the "London Medical Gazette." The accident hap- 
pened to a young hussar, who was riding without stirrups, and was 
occasioned, as in the case first mentioned, by the knee having been for- 
cibly struck by a soldier in the opposite rank. The patella was half 
turned on its axis, so as to have one edge directed backwards and rest- 
ing on the outer edge of the trochlea of the femur, while the other edge 
projected directly forwards ; the posterior surface was directed outwards, 
and the anterior inwards. 

The surgeon, finding it impossible by any force to restore the patella 
to its proper situation, had recourse to the expedient of cutting through 
the quadriceps tendon, where it is attached to the patella, but not even 
then could he effect replacement. Unhappily the incision extended into 
the joint, and was followed by suppuration, in consequence of which the 
patient died about eleven months after the accident. 

DISLOCATIONS OF THE TIBIA FROM THE FEMUR. 

The tibia may be dislocated in four directions, — inwards, outwards, 
backwards, or forwards. The last two are complete ; the other Wo, or 
lateral dislocations, are partial. 

THE LATERAL DISLOCATIONS. 

The two lateral dislocations are easily distinguished by the appear- 
ance of the deformity, and the immovable condition of the joint. They 
are reduced by extension and counter-extension, and by pressing the 
tibia inwards or outwards, according to the direction of the dislocation. 
The external condyle of the femur, in the dislocation outwards, rests on 
the internal condyle of the tibia ; in the dislocation inwards, the internal 
condyle of the femur rests on the external condyle of the tibia. In 
both dislocations the tibia is a little twisted. 



DISLOCATIONS OF THE ANKLE JOINT. 279 



DISLOCATION FORWARDS. 

Symptoms. — The symptoms of this dislocation, — are a great swell- 
ing in the popliteal region, caused by the under extremity of the femur, 
and another in front of the femur, caused by the tibia, patella, and 
fibula being driven upwards and forwards upon it ; a shortening of the 
leg, to an extent varying according to the distance that the tibia is sent 
up upon the femur ; a very slight flexion of the leg upon the thigh, so 
as to form a very obtuse angle ; and the extremely unnatural appearance 
caused by the deformity. In some cases, the pain has been very severe, 
and from the pressure of the femur against the popliteal artery, the 
pulsation of the anterior tibial artery has been found in some examples 
to be interrupted, in others the condition of the vessel has not been 
observed. 

Reduction. — Reduction is easily accomplished by counter-extension 
applied to the thigh, and extension to the leg, in the direction of the 
#long axis of the displaced tibia ; and while these are being employed by 
assistants, the surgeon, placing one hand on the popliteal space against 
the extremity of the femur, and the other in front of the joint against 
the tibia, presses in opposite directions so as to send the femur upwards 
and forwards, and the tibia downwards and backwards. After reduc- 
tion, the limb should be laid straight, and precautions taken to prevent 
inflammation. If, notwithstanding these precautions, inflammation 
should occur, active remedies must at once be employed to subdue it. 

DISLOCATION BACKWARDS. 

Symptoms. — A shortened state of the limb, the leg bent very much 
forward, a swelling in the popliteal space caused by the tibia, another 
in front, caused by the femur, and a great depression below it, in the 
situation of the ligamentum patellae, are the symptoms of this disloca- 
tion. 

Reduction. — The method of reduction is the same as in the last dis- 
location, except that the surgeon should press the extremity of the 
femur upwards and backwards, and the head of the tibia downwards 
and forwards, while extension and counter-extension are being made. 

DISLOCATIONS OP THE ANKLE JOINT. 

The ankle joint, which is formed by three bones, the tibia, fibula, and 
astragalus, and strengthened by five ligaments, the two tibio-tarsal and 
the three peroneo-tarsal, is liable to five dislocations. The tibia may 
be displaced from the astragalus, inwards, outwards, completely for- 
wards, partially forwards, and backwards. 

DISLOCATION OF THE TIBIA INWARDS. 

Symptoms. — This dislocation may be readily distinguished by the 
great projection of' the malleolus externus against the common integu- 
ment, by the foot being turned outwards, by its inner edge being directed 
downwards, and by the depression about two or three inches above the 
malleolus externus, where crepitus may be easily detected. The pain 
is very great, and the swelling considerable ; the foot can be moved by 



280 



DISLOCATIONS OF THE ANKLE JOINT. 



the surgeon without difficulty, and when the patient is in the erect atti- 
tude, the inner edge only can be applied to the ground. 



Fig. SI 




State of the Parts. — The tibia is drawn inwards, and before it can 
be brought into this position the tibio-tarsal ligaments must be ruptured, 
and the fibula fractured. This fracture takes place about two or three 
inches above the joint, and furnishes an explanation of some of the 
symptoms above mentioned. The under part of the fibula remains at- 
tached to the tarsus by the peroneo-tarsal ligaments which are entire. 

Besides fracture of the fibula 
Fi S- 84. and rupture of the tibio-tarsal 

ligaments — conditions which 
always exist in this accident, 
there is often oblique fracture 
of the tibia, directed so as to 
break off from the shaft of the 
bone that part of the tibia 
which enters into the forma- 
tion of the inferior tibio-fibular 
articulation. The fragment 
thus broken off remains con- 
nected with the malleolus ex- 
ternus, while the tibia, entire 
along the whole of its inner 
aspect, is carried inwards along with the part of the fibula above the 
fracture. 




DISLOCATIONS OF THE ANKLE JOINT. 281 

Treatment. — For accomplishing reduction, the surgeon should direct 
the patient to be placed upon his back, with the thigh raised perpen- 
dicularly, and the leg bent back so as to make a right angle with the 
thigh. In this position the gastrocnemius muscle will be relaxed, and 
the extremity will be conveniently placed for applying the necessary 
extension and counter-extension. Surgeons have sometimes experienced 
difficulty in accomplishing reduction, from attempting it when the limb 
is extended, and, the gastrocnemius thereby put upon the stretch. One 
assistant should afford the necessary counter-extension by holding the 
thigh, and another the necessary extension, by drawing the foot in a 
line with the long axis of the leg, preserving the foot, at the same time, 
midway between flexion and extension of the ankle joint, while the 
surgeon endeavours to press the tibia outwards, so as to bring it into 
contact with the upper surface of the astragalus. After reduction, the 
limb should be placed upon the posterior part, with the leg a little bent 
on the thigh, and the foot midway between flexion and extension, — a 
position which will be favourable to the uniform relaxation of the 
muscles. Until the fibula becomes entire, and the tib'io-tarsal ligaments 
unite, appliances must be used for preventing the foot from being drawn 
outwards ; for which purpose, two splints, each having a foot-piece, may 
be employed, or one splint without a foot-piece, applied to the inner, 
and one, with a foot-piece, applied to the outer side, to compensate for 
the want of resistance naturally offered by the fibula to the foot being 
drawn outwards. The most suitable means for keeping the splints in 
their proper position are loop or buckle-bandages. Some cotton-wool 
should be used to prevent the splints from pressing unpleasantly against 
the limb and foot. A point of the very greatest importance is to apply 
the splints so very loosely at first, as to make it impossible for them to 
prove injurious by producing pressure upon the affected parts, which 
often swell to' a very considerable extent, in consequence of inflamma- 
tion supervening. After what has been stated regarding the different 
varieties of apparatus for retaining the foot in its proper position in 
fractures, it is unnecessary here to refer to other appliances for the 
treatment of lateral dislocations of the ankle; for a description of them, 
and their mode of operation, I beg to refer to the section on Fractures of 
the leg. 

DISLOCATION OF THE TIBIA OUTWARDS. 

Symptoms. — The malleolus externus projects against the common 
integument, forming a remarkable swelling in that situation, the foot is 
turned inwards and its outer edge rests upon the ground. 

State of the Parts. — The tibia cannot be sent to the outer side of the 
astragalus, the position which it occupies in this dislocation, without the 
malleolus internus being fractured. The dissevered malleolus remains 
attached to the tarsus by the tibio-tarsal ligaments. The fibula is sent 
outwards from the tarsus, and the peroneo-tarsal ligaments are usually 
ruptured ; sometimes they are entire, but in that case the fibula is frac- 
tured above the malleolus, and the under part of the fragment remains at- 
tached to the tarsus, while the upper part of the same fragment is bent 



282 



DISLOCATIONS OF THE ANKLE JOINT. 



outwards. The condition of the parts, therefore, may be stated to 

be, — that the malleolus internus 
Fig. 85. is broken off from the tibia, and 

remains attached to the tarsus by 
the tibio-tarsal ligaments, and 
the peroneo-tarsal ligaments are 
ruptured ; or, the two malleoli 
are fractured, and the peroneo- 
tarsal ligaments are entire. That 
such are the conditions in this 
dislocation I am fully satisfied. 

Treatment. — The method of 
reduction differs from that in the 
former dislocation only in this 
respect, that the surgeon presses 
the bones inwards instead of out- 
wards. After reduction, the at- 
titude and the treatment are 
precisely the same, except that if 
one splint only have a foot-piece, 
it must be applied to the inner 
instead of the outer side ; because 
the object of the foot-piece is to 
preserve the foot in its proper 
position, and in this dislocation 
the foot has a tendency to be 
drawn inwards. This dislocation 
may also be very conveniently 
treated by the different appliances 
mentioned in the description of 
the treatment of fractures of the 
leg. In the two lateral dislocations, if Dupuytren's splint be used, it 
must always be fixed to the side opposite to that towards which the foot 
is in danger of being drawn ; because, in this case, it is not the splint 
that prevents displacement, but the bandage, which fixes the foot to the 
splint. 

DISLOCATIONS FORWARDS. 

These, as has been already stated, are two, the complete, and the 
partial. 

Symptoms. — The heel is lengthened, fixed, and drawn upwards, the 
part of the foot before the leg is proportionally shortened, and the toes 
are depressed. These symptoms in the two dislocations differ merely 
as to their extent. In the complete dislocation, there is an evident de- 
pression in front of the tendo Achillis, and the foot is even more rigidly 
fixed than in the partial dislocation. 

State of the Parts. — In the complete dislocation, the fibula is frac- 
tured, and the fragment remains attached to the tarsus by the peroneo- 
tarsal ligaments, the tibio-tarsal ligaments are ruptured, and the tibia 
rests on the os naviculare, and the os cuneiforme internum. In the 
partial dislocation, also, the fibula has been found fractured, the tibio- 




DISLOCATIONS OF THE ANKLE JOINT. 283 

tarsal ligaments ruptured, and the tibia resting partly on the astragalus, 
and partly on the os naviculare. 

Treatment. — Reduction is accomplished as in the lateral dislocations, 
except that the bones of the leg should be pressed backwards while 
extension and counter-extension are being made, and the extension 
applied to the foot should be directed so as to bring the astragalus in a 
line with the long axis of the leg. The limb should be placed in the 
same attitude as in the former dislocations, and by bandaging the leg 
and foot to two splints with foot-pieces, it is possible to keep the bones 
of the leg from slipping forwards ; but by far the most efficient and 
convenient retentive apparatus for the treatment of this injury is Ames- 
bury's double-inclined plane. By means of it the bones of the leg can 
easily be kept from sliding forwards, until the fractured portions of the 
tibia unite, and the ruptured ligaments are restored. 

DISLOCATION OF THE TIBIA BACKWARDS. 

This is an extremely rare injury. I once had an ppportunity of see- 
ing an example of it in a girl fourteen years of age. When I saw the 
patient, about two years had elapsed since the occurrence of the disloca- 
tion, and no attempt had been made meanwhile, to accomplish reduction ; 
the surgeon who first saw the case after the injury, not understanding 
the nature of it. The symptoms were, — great lengthening of the foot 
before the two malleoli ; the heel and back of the leg were in a line with 
each other, so that there was no projection whatever of the foot behind 
the leg ; the malleoli did not appear to have been fractured, but were 
equally driven backwards, so as to bear their natural relations to each 
other ; and the foot did not present any twisted appearance. When 
the girl was raised to the erect attitude, and when she pressed with any 
weight upon the foot, its anterior extremity bent upwards, in conse- 
quence of which she was unable to use the foot in walking. In this 
case, the tibio-tarsal and peroneo-tarsal ligaments must have been rup- 
tured ; the malleoli appeared to be free from fracture, and the tibia 
rested upon the upper part of the calcaneum. 

Treatment. — For accomplishing reduction in a recent case, the pa- 
tient should be placed in the same attitude as in the reduction of the 
former dislocations ; counter-extension should be applied to the thigh 
by one assistant, and extension to the foot by another ; and while the 
foot is being drawn in a line with the long axis of the leg, it ought, at 
the same time, to be carried backwards, so as to bring the astragalus 
underneath the tibia. While counter-extension and extension are being 
made, the surgeon should endeavour to press the tibia forwards. Ames- 
bury's double-inclined plane, with a large pad placed between the 
splint and the back of the leg, immediately above the heel, will be found 
the most convenient retentive apparatus. 

COMPOUND OR OPEN DISLOCATION OF THE ANKLE JOINT. 

Together with displacement of the bones of the leg in any of the di- 
rections above referred to, there may also be a wound of the soft parts, 
laying open the cavity of the joint, constituting what is called a com- 
pound or open dislocation. The cause of the wound may be the protru- 
sion of the bones through the soft parts, or the tearing of the soft parts 



284 DISLOCATIONS OF THE ANKLE JOINT. 

by some hard body, against which the limb may have been pressed. 
The former is the more frequent cause, but in whatever way produced, 
this injury is always of a very serious character. Inflammation of the 
synovial membrane, and irritative fever, are the consequences of this 
condition ; and extensive suppuration, destruction of the cartilages, and 
gangrene of the soft tissues are the local results principally to be dreaded 
from that inflammation. These open dislocations were at one time con- 
sidered to be so dangerous, that immediate amputation was deemed not 
merely expedient, but absolutely necessary to save the life of the pa- 
tient. But in so many cases, even with serious complications, the limb 
has been saved, and the treatment been successful, that no surgeon of 
the present day would think of amputating on account of a dislocation 
being compound, unless it were attended by other unfavourable compli- 
cations. In the greater number of cases, the practice to be followed is, 
to reduce the dislocation, bring the edges of the wound together, and 
treat the case as the common rules of surgery indicate. 

There are, however, certain conditions which render amputation ad- 
visable and necessary, the principal of which are : — an extremely shat- 
tered condition of the bones ; a very extensively lacerated wound ; severe 
and extensive contusion of soft parts about the joint, so as to make it 
probable that sloughing will take place ; division of the larger blood- 
vessels, together with an extensive wound ; a very irritable or debilitated 
constitution ; or the advanced age of the patient. Such are the chief 
circumstances which render it judicious for the surgeon to recommend 
immediate amputation, rather than endanger the life of the patient by 
attempting to save the limb. When amputation is deemed necessary, 
the proper period for its performance is before the occurrence of irrita- 
tive fever : if that period be allowed to pass by, another may not occur 
in which the operation could with propriety be performed. The above 
conditions in many instances justify immediate amputation. Sometimes, 
when attempts have been made to avoid amputation in the first instance, 
it has -been ultimately rendered indispensable by extensive suppuration, 
or by destruction of portions of the bones keeping up constant irritation 
in the system, or by gangrene of the foot. When this last condition 
occurs, it is exceedingly desirable to have the limits of the gangrene 
fixed before the operation be attempted ; although it has been ascer- 
tained, that it is not so absolutely indispensable to have limits set in 
gangrene arising from destruction of vessels in a healthy person, as in 
gangrene arising from a constitutional cause. 

I shall conclude the subject of compound dislocation of the ankle 
joint with the following quotation from the work of Sir Astley Cooper. 

" Persons who are much loaded with adeps are generally very irri- 
table, and bear important accidents very ill; indeed they frequently 
perish, whatever plan of treatment is pursued : to this statement, how- 
ever, there are exceptions in those who, though corpulent, are still in 
the habit of taking much exercise, as they will retain some vigour of 
constitution ; and in such persons the limb may be attempted to be 
saved as in the case described by Mr. Abbot, surgeon, at Needham 
Market ; but in those who have become extremely fat, and who have 
been addicted to habits of indolence, there is but little chance of pre- 
serving life but by amputation." 



285 



CHAPTER VIII. 

AFFECTIONS OF THE OSSEOUS SYSTEM. 

PERIOSTITIS. 

Sir Philip Crampton, of Dublin, who first gave this name to in- 
flammation of the periosteum, has the merit of being the first person 
who gave a description of that form of the disease which proceeds from 
cold or external injury, and is called Idiopathic, to distinguish it from 
the symptomatic form, which is the effect of scrofula, syphilis, or the 
injudicious use of mercury. Professor Graves, of Dublin, in his excel- 
lent Clinical Lectures, divides this disease into two forms,-^-the diffused 
and the circumscribed, the former corresponding with the idiopathic, the 
latter with the symptomatic of Sir Philip Crampton. 

Periostitis may be either acute or chronic. When it occurs in a 
person of sound constitution, and is occasioned by cold or external 
injury, it is usually acute ; when it is of the symptomatic or circum- 
scribed form, it is generally chronic ; and when it is excited by external 
causes in a person predisposed to the disease by scrofula, syphilis, or 
the too free use of mercury, it often exhibits both the acute and the 
chronic form. 

Causes. — The causes of periostitis may be divided into exciting, 
and predisposing. Of idiopathic periostitis the exciting causes are 
atmospheric influence, and mechanical injury ; the predisposing causes, 
a feeble, debilitated state of body, induced by mental anxiety, or 
long-continued derangement of the digestive apparatus. Of symp- 
tomatic periostitis, the exciting causes, — although this form of the 
disease sometimes occurs without any known exciting cause, — are the 
same as those of the idiopathic form. The predisposing causes are 
scrofula, syphilis, or an irritable condition of the constitution caused by 
the prejudicial use of mercury. If in any unfortunate person, the sub- 
ject of an attack of periostitis, "the triumvirate of scrofula, syphilis, 
and mercury," as an excellent writer has expressed himself, should 
chance to meet, the symptomatic form will be, in all probability, of the 
very worst kind. The causes may be, therefore termed the external or 
exciting, and the internal or predisposing. 

Periostitis is most common to bones situated near the surface of the 
body, as the cranium, clavicle, sternum, and tibia: the pericranium 
over the frontal bone, on account of its exposed situation, is frequently 
the subject of the disease ; sometimes also the periosteum of the humerus 
is attacked by it, and occasionally that of the femur. 



286 DISEASES OF THE PERIOSTEUM. 

Symptoms. — The symptoms in some degree differ according as the 
disease is of the acute or chronic form. We shall, however, consider 
the symptoms of both forms together, noticing the differences as we 
proceed. 

Deep-seated pain is one of the earliest and most urgent symptoms. 
It is severe on account of the unyielding nature of the tissue affected, 
and is of a girding nature, and in some conditions attended with throb- 
bing. In acute periostitis it is constant, and, like the pain caused by 
inflammations of the most hard tissues, is characterized by remissions 
and periodical exacerbations ; the exacerbations occurring during the 
night, when the pain is often most excruciating. In the chronic form, 
the pain is so much diminished during the day, as to be intermittent ; 
but the nocturnal exacerbations are particularly distressing. 

Together with pain, there is extreme tenderness on pressure, some- 
times amounting even to intolerance of touch. This symptom is much 
greater in periostitis than in ostitis. 

Sivelling is, comparatively speaking, an early symptom, and is also 
subject to variety during the different stages of the disease. In the 
first stage, the swelling is of an elastic, tense, doughy feeling, depen- 
dent on the swollen condition of the periosteum itself ; it may afterwards 
become cedematous, from effusion into the cellular tissue external to the 
periosteum, but there is always the elastic feeling underneath this 
oedema. The ultimate character, however, of the swelling will vary, 
both as to hardness and extent, according as the periostitis is acute or 
chronic. The varieties and conditions on which they depend, will be 
understood from the description of the state of the parts given in 
another page. Often in the very chronic form, the swelling, at first 
elastic, ultimately becomes quite hard; but it is only in this form, and 
after long continuance of it, that we find on pressing it firmly with the 
fingers, that rigid, incompressible hardness which characterizes swelling 
of the bone itself. The skin is at first pale, and not involved in the 
disease ; but if the disease be acute, the swelling, sooner or later, 
becomes diffused, and the skin red, tense, tender, and glistening. 

Constitutional Symptoms. — Periostitis is accompanied with evident 
constitutional symptoms. In the acute form they are the same as those 
of inflammatory fever, but of a more aggravated character, and attended 
with great derangement of the digestive apparatus. In the chronic form 
the patient becomes pallid, weak, relaxed, and emaciated, from continued 
irritation and want of sleep, and exhibits the symptoms of hectic fever. 
In short, the accompanying fever is of the inflammatory type in acute, 
and ere long becomes of the hectic type in chronic periostitis. There 
is, however, one condition of the acute form of the disease, in which the 
inflammatory fever which attends the very commencement, is speedily 
converted into hectic fever ; namely, when suppuration takes place to 
a great extent. 

State of the Parts. — One of the earliest pathological changes is in- 
creased vascularity of the periosteum. In the acute form the periosteum 
is thickened and softened, while in the chronic it is thickened, and its 
density increased. Sometimes it is thickened without effusion under it, 
and then there may be increased adhesion of the periosteum to the 



DISEASES OF THE PERIOSTEUM. 287 

bone, with increased vascularity of the bone j and this, if not relieved, 
may, after considerable suffering and derangement of the general health, 
terminate in the conversion of the periosteum into a fibro-cartilaginous 
substance. This is usually attended at last with some swelling of the 
bone itself. If there be no subsidence of the inflammation in periostitis, 
effusion may take place both inside and outside the periosteum ; effusion 
of serous fluid into the surrounding cellular tissue giving rise to oedema, 
and secretion *of fibrin taking place underneath the periosteum between 
it and the bone. The secretion of fibrin under the periosteum is more 
likely to take place in the chronic form, and is termed by some the ge- 
latinous effusion. "The bone," Mr. Liston observes, " is imbedded in 
a gelatinous or lymphatic effusion situated mostly beneath the perios- 
teum." Inflammatory or recent node is the name distinguishing this 
raised condition of the periosteum caused by the effusion of lymph ; and 
if the inflammation does not go on to a more acute stage, the effusion 
may be converted into cartilage, and then into bone, forming permanent 
node. Other products of inflammation may be formed in the acute 
variety : if the inflammation be great, purulent matter may be formed 
between the periosteum and the bone, causing separation of the perios- 
teum. Sometimes the separation is extensive, and necrosis of the bone 
from inflammation, and from the loss of its nutritive membrane, may be 
the result. It is when the suppuration is extensive and takes place 
very speedily, that the inflammatory fever which attends the very be- 
ginning of the disease may be so quickly converted into the hectic type. 
There is a form of periostitis termed by some paronychia periostei, or 
the deep-seated paronychia, or whitlow, and by others the paronychia 
maligna. This is an example of severe acute periostitis, and affects the 
phalanges of the fingers and their periosteum. In this variety the pain 
of the finger is excessive ; it feels as if it would burst ; there is great 
oedema and swelling of the hand, and often the whole finger appears as 
if affected with erysipelatous inflammation. Suppuration to a conside- 
rable extent, sloughing of the soft parts, and destruction of some of the 
bones are sometimes consequences of this form of periostitis. 

Treatment. — The mode of treatment differs in the acute and chronic 
forms. 

In the acute form, the constitutional treatment consists of low diet, 
general depletion, saline purgatives, diaphoretic medicines, and such 
means as are capable of procuring resolution. The local treatment in- 
cludes quiet, an attitude favourable to the reflux of the venous blood, 
leeches, warm and emollient applications, as fomentations, poultices, 
and other antiphlogistic means. Free division of the periosteum should 
be employed, according to some, only when other treatment has failed. 
Professor Miller objects to free direct division if suppuration be not 
present, and recommends a valvular division of the inflamed periosteum. 
Professor Syme says, " The mode of treatment depends upon the inten- 
sity of the symptoms. When they are very violent and attended with 
smart fever, the most effectual practice is to make a free incision through 
the inflamed parts down to the bone. When less severe, no benefit is 
derived from- this proceeding." 

"Free incisions," says Mr. Liston, "through the periosteum some- 



288 DISEASES OF THE PERIOSTEUM. 

times relieve the pain, and cut short the disease, the distended vessels 
being thereby emptied ; but such practice is only a last resource, when 
the action has resisted all other means and threatens an unfavourable 
termination." If, in the acute form, the inflammation proceeds to sup- 
puration, free division is the more necessary. But whether suppuration 
be present or not, the distended vessels ought to be relieved by early 
free direct incision, if other treatment prove unsuccessful. 

In the chronic form, the constitutional treatment consists in the ex- 
hibition of internal alterative remedies, as hydriodate of potass, which, 
to prove efficacious, must be administered in pretty large quantities, say 
of about ten grains in divided doses during the day. It may be given 
in water, or combined with sarsaparilla, which is itself an excellent 
alterative. Some authors deprecate the employment of powerful alte- 
ratives, unless all others have failed. Mercurial alteratives are found 
exceedingly useful in relieving chronic periostitis, and should be tried, 
if the body be not exceedingly irritable, and if the above treatment 
have not had the desired effect. It seems strange that mercury, a pre- 
disposing cause of periostitis, should prove a remedy ; yet that it does 
so, is an ascertained fact. Bichloride of mercury answers well, and 
may be given in doses of a tenth of a grain twice or thrice a day, either 
made into a pill, or in solution in sarsaparilla. " General chronic 
periostitis, which is produced by exposure to cold, or occurs often during 
mercurial courses, and is often supposed to be a symptom of syphilis, is 
relieved by the internal exhibition of bichloride of mercury, or other 
mercurial preparations, combined with sarsaparilla and diaphoretics. 
In many instances such an affection will yield to no other treatment, 
and thus the practitioner is occasionally obliged to have recourse to a 
somewhat paradoxical practice, that of giving mercury for a disease 
which seems to have been produced by that mineral." The foregoing 
passage is borrowed from Mr. Liston's "Elements of Surgery." Upon 
this point Mr. Lawrence remarks ; — "I have seen, in so many instances, 
the pain in that disease continue unrelieved, in spite of the pretty active 
employment of local antiphlogistic means, in spite of mild mercurial 
treatment, and have so constantly found it yield only to the full in- 
fluence of mercury on the system, that I own myself to be at a conside- 
rable loss to account for the opinion entertained by many, that inflam- 
mation of the periosteum and affections of the bone are actually brought 
on by the use of mercury. It seems to me to be very inconsistent that 
one and the same medicine should be capable of decidedly relieving in- 
flammation of a certain texture, and that when employed for other pur- 
poses it should actually produce inflammation of that very texture. I 
think I formerly had occasion to mention that I did not coincide with 
the opinion of many, that those states were produced by the mercury, 
and certainly, when speaking of inflammation of the periosteum, whether 
arising from syphilis or not, I do not know of any means so capable of 
relieving the disorder as mercury. 

Local Treatment comprises the use of some of the different forms of 
counter-irritants. Blisters are sometimes very useful ; and in some 
cases the local application of an alterative, as mercurial ointment rubbed 



DISEASES OF THE PERIOSTEUM. 289 

into the part, or painting it frequently with tincture of iodine, may be 
found beneficial. 

NEURALGIA PERIOSTEI. 

This very painful affection sometimes follows amputations, or slight 
injuries of a bone ; sometimes it affects the periosteum of the ribs and 
sternum in cases of spinal irritation or uterine derangement, when a 
morbid sensibility in the sentient extremities of nerves is by no means 
an unusual condition ; and sometimes it comes on without any known 
exciting cause. The disease generally affects females of weak constitu- 
tion, though males of an irritable habit are also subject to it. I have 
met with many examples of this affection in females of a hysterical habit, 
and two instances of it I have seen in males, one of the periosteum of 
the ribs in a young man who died of phthisis, and the other of the peri- 
osteum of the humerus in a gentleman who never had any complaint 
beyond derangement of the digestive apparatus, and neuralgic pains 
about the face. 

Symptoms. — One of the earliest and most urgent symptoms is severe 
pain, of a sharp neuralgic kind, sometimes so severe as to deprive the 
patient of sleep ; and like all neuralgic pains, intermitting, and often 
periodically recurring. Extreme tenderness on pressure is often a 
symptom, and in some cases the nervous sensibility is so much exalted 
that the slightest touch is painful. Sometimes, but not always, this 
tenderness to touch extends to the common integument. In the ex- 
ample of the affection which I met with in the periosteum covering the 
ribs, the integuments could be pinched up, and pressure directed against 
the intercostal spaces without causing any uneasiness ; but the slightest 
pressure directed against the ribs occasioned great pain. Mr. Thomas 
Spencer Wells, in an excellent article on diseases of the bones, in the 
"Cyclopaedia of Practical Surgery," states, that he met with two ex- 
amples of this affection of the periosteum covering the ribs in two young 
men who had fallen into phthisis after syphilis and the too free use of 
mercury ; and in both these instances the pain on pressure was entirely 
confined to the periosteum. The only opportunity I have had of ex- 
amining the periosteum after death, was in the case of phthisis above 
referred to. There was not the slightest trace of inflammation, nor any 
apparent change whatever in either the periosteum or the bone ; and 
though there have been many cases, in which persons who had suffered 
from this affection, have been examined after death arising from other 
causes, without the surgeon having been able to detect any trace of 
vascular hypersemia. The conclusion drawn from hence is, that neu- 
ralgia periostei depends upon a painful exaltation of the function of the 
sentient nerves of the periosteum. 

Treatment. — This disease must be combatted by general and local 
treatment. The object aimed at by general treatment is to give in- 
creased tone and strength to the system, and the means to be used for 
this purpose must be suited to the particular state of the patient. Ex- 
ercise and free exposure in the open air, a generous diet, and the due 
regulation of the bowels, together with tonics, such as preparations of 
iron, and more particularly the carbonate and the saccharated carbonate 



290 OSTITIS. 

of iron, are prescribed with advantage when the patient is not suffering 
from any other disease, and when no symptoms appear indicating that 
their employment would be prejudicial. As local applications, different 
anodyne liniments, and plasters containing opium or belladonna, or both, 
are useful. I have often prescribed, apparently with advantage, a lini- 
ment of equal parts of the tincture of belladonna, and the tincture of 
opium, to be kept constantly over the part ; and I have seen plasters 
containing large quantities of- belladonna or opium, or both, very ser- 
viceable ; liniments and plasters containing aconite, are also very useful. 
The above are the only local applications of which I have had any ex- 
perience, with the exception of the endermoid application of nitrate of 
silver, which I have known to prove exceedingly useful. 

OSTITIS. 

Ostitis is the name given to inflammation of bone. It may arise from 
cold, external injury, periostitis, or neglected or improperly treated 
phlegmonous erysipelas :— in the latter case, the inflammation spreads 
from the soft parts to the periosteum and bone, so that they become 
secondarily affected. It is also often induced by inflammation of the 
synovial membrane at the extremity of a bone. These may be called 
the external and exciting causes ; and when they induce the disease in 
a person of sound constitution, it is then said to be simple ostitis ; but 
when the constitution of the patient has been previously affected by 
scrofula, syphilis, or mercury, which are predisposing causes, the dis- 
eased action is then modified by the general state of the system, and 
the ostitis is termed specific. It is of importance to understand how far 
the inflammation of the specific forms can be distinguished from that of 
the simple by their effects, and to ascertain as far as they are known, 
the characteristic appearances of each. Ostitis may not only be either 
simple or specific, but also like other inflammations, either acute or 
chronic. 

Symptoms. — In the acute form, one of the earliest symptoms is deep- 
seated agonizing pain, which by the patient is referred to the bone. 
The pain is even more excruciating than in periostitis, and is of a burst- 
ing kind. It is less aggravated by pressure than periostitis, and, as in 
that disease, it has nocturnal exacerbations. In the acute forms there 
are occasional remissions of the pain, but in the chronic form there are 
often complete intermissions. The pain is increased by motion of the 
limb, and by the dependent posture. In ostitis, tenderness to the touch 
at first is slight ; in periostitis it is the reverse, so that this symptom is 
diagnostic at an early stage of the disease ; but afterwards the perios- 
teum becomes inflamed, and then there is the same acute tenderness as 
when that membrane is primarily affected. Swelling is long before it 
makes its appearance, and when it does, it is for some time hard, solid, 
and diffused, afterwards it becomes oedematous from effusion into the 
cellular tissue, and the soft tissues over the bone at last present the 
ordinary local symptoms of inflammation. The constitutional symptoms 
are those of inflammatory fever, and their violence will depend on the 
intensity, extent, and duration of the disease, and the susceptibility of 
the constitution to sympathize with the local action. 



OSTITIS. 291 

In the chronic form, pain is the earliest symptom. Compared, how- 
ever, with the pain in the acute form, it is inconsiderable ; and while it 
has distinct exacerbations during the night, it is always marked by de- 
cided remissions, and often by complete intermissions during the day : 
— this is for a long time the only local symptom. Swelling is long be- 
fore making its appearance, and when it does, it is much more circum- 
scribed than in the acute form, and is characterized by an unyielding 
incompressible hardness. If the periosteum become affected, the swell- 
ing will at last present the character of the same symptom in chronic 
periostitis ; but it is slower in its progress, and longer in making its 
appearance, than in that disease. In the early stage, pressure has little 
or no effect in aggravating the pain, and it is often a long time before 
the patient complains of tenderness when the bone is pressed. There 
is very little sympathetic effect produced in other parts of the system 
until the disease has been of long standing ; and when the continuance 
of the nocturnal exacerbations and want of rest cause constitutional 
disturbance, the fever is of the hectic type. 

State of the Parts. — The changes produced in the osseous structure, 
by acute inflammation, during the period of its activity, and before 
reaching suppuration, whether external, internal, or general, simple or 
carious ulceration, or some of the different forms of necrosis, are but 
imperfectly known. The blood-vessels have been found more numerous 
and distended than natural. The bone becomes softened, apparently 
from absorption of part of its earthy matter, its cancellated texture 
appears unusually open, the lamellre are thinned, and the haversian 
canals become preternaturally large, as if the distended vessels pressed 
aside the softened structure. This last-mentioned condition sometimes 
gives the bone, especially on the surface, a porous appearance. Exuda- 
tion takes place both into the cells and into the haversian canals. Such 
are the principal conditions produced, in the first instance, by acute in- 
flammation in a bone not the subject of any previous unhealthy deposit. 
After some time, the following changes may take place in acute ostitis. 
The inflammation may result in resolution, or in one of the varieties of 
suppuration, which will afterwards be described ; or it may lead to 
simple or carious ulceration, or to necrosis. If the inflammation be of 
a more chronic character, other changes may take place. Sometimes 
the bone becomes expanded or enlarged, and, at the same time, espe- 
cially in syphilitic patients, consolidated, and its weight increased. 
These changes, caused by the plastic exudation passing into bone, may 
either affect the entire bone, or be confined to a particular region of it, 
which has been more especially the subject of inflammation. This 
osseous formation taking place upon the inner surface of the haversian 
canals, their cavities become more or less filled up, so that in many 
cases, a section of the diseased part presents a nearly uniform ivory- 
like texture, in which few orifices appear. Sometimes these deposits 
are in the cavities of the long bones, making them almost solid through- 
out ; and often, they are found on the surface, occasioning protuberances, 
rendering the bone rough or uneven, and considerably altering its figure 
and appearance. In scrofulous subjects, the bone becomes very much 
lighter than natural, and is filled with a cheese-like substance. In some 



292 SUPPURATION IN BONE. 

specimens in my collection, this substance occupies only part of a bone ; 
in others it extends through almost the whole of a bone, occupying nearly 
the entire space within the shell, which is exceedingly thin, and in these 
instances the whole of the earthy matter is absorbed, except that which 
forms the very thin external shell. In other specimens, this peculiar 
deposit is equally extended through the whole of a bone, but seems to 
be diffused through the cancellated structure, which is not entirely ab- 
sorbed. In some, of the specimens, where this substance is general 
through the whole of a bone, and where the shell is very thin, there are 
small deposits of bone, forming osseous irregularities, or spicula, on the 
external surface. The colour of this substance is in some cases pure 
white, in some, yellowish white, and in others, reddish brown. In many 
cases, traces of inflammation accompany this cheese-like deposit, while 
in others, no such traces are apparent. It may result from previous 
perversion of nutrition, unattended with inflammation ; or it may be a 
transformation of the liquor sanguinis exuded in consequence of a low 
grade of the inflammatory process, in a person of scrofulous diathesis. 
The subject of such deposits will be more particularly referred to in the 
description of tubercle, in the chapter on Tumours. 

Treatment. — This may be summed up in a very few words. It is 
both general and local. In the acute form, the treatment is precisely 
the same as in periostitis, except that there is no necessity for incision. 
In all cases the treatment should be decided, that the inflammation may, 
if possible, be prevented from going on to suppuration or caries. The 
local and general depletion, however, must not be carried to too great 
an extent, as the consequent debility predisposes to caries. In the 
chronic form, the treatment consists locally, in the employment of the 
different counter-irritants; and internally, of the alterative remedies 
recommended in the treatment of periostitis ; but it should be remem- 
bered that mercury, although often useful, ought to be exhibited with 
the greatest caution, as the interstitial absorption arising from the free 
use of this medicine in some forms of ostitis, increases the danger of 
the occurrence of caries. 

SUPPURATION IN BONE. 

Suppuration may be divided into three varieties — namely, external, 
internal, and general. 

Of external suppuration, there are two kinds, acute and chronic ; 
each presenting a different assemblage of symptoms, and requiring dif- 
ferent treatment. 

Acute External Suppuration, or acute external abscess, is a frequent 
consequence of periostitis, or ostitis, or both. 

Symptoms. — Pain of an excruciating kind, attended with the other 
symptoms of ostitis, if that be the cause of the disease — rigors recurring 
at intervals, and swelling, which has a feeling of fluctuation. The 
integuments ultimately present the local symptoms of inflammation. 
Absorption, ulceration, caries, and even necrosis of the bone may be 
produced, if the purulent matter which burrows beneath the periosteum 
be not speedily evacuated. 



SUPPURATION IN BONE. 293 

Treatment. — Before the abscess is formed, the surgeon should endea- 
vour to remove the inflammatory action by the usual antiphlogistic 
remedies ; but after its formation the appropriate treatment is free, 
direct incision, which affords very great relief to the patient. 

Chronic External Suppuration, or chronic external abscess, may be 
the consequence of an attack of chronic inflammation, which may have 
commenced in the bone, or in the periosteum, or in both of these tissues. 

Symptoms. — These at first are the same as the symptoms of chronic 
periostitis, or chronic ostitis, or of both these diseases. After some 
time a swelling with fluctuation forms, unattended with the symptoms 
of acute inflammation. The swelling is generally small and circumscribed, 
just the reverse of what takes place in chronic abscess of the soft parts. 

Treatment. — The treatment proper to be first tried is the same as in 
small chronic abscess of the soft tissues ; accordingly all means likely 
to produce absorption should be employed. With this view it is neces- 
sary to improve the general health, and to enjoin dry and solid food, 
and abstinence from liquids ; in addition to which, internal alterative 
remedies, as iodide of potassium, should be given in 'small quantities, — 
four or five grains in solution, in divided doses, during the day will often 
be found beneficial. The local treatment consists in the employment 
of various applications used to promote absorption. For this purpose 
it has, in many instances, been found advantageous to paint the part 
with the tincture of iodine, as frequently as the state of the skin will 
permit. A lotion of iodide of potassium, iodine, and water, of the pro- 
portions of 5ii of the iodide of potassium, 31 of iodine, and ^i of water, 
is sometimes used in the same manner as the tincture, and with good 
effect. Some apply blisters, from their well-known effect of sometimes 
promoting absorption ; others use blisters, and dress the part with 
mercurial ointment. If these means do not effect a cure, a small valvular 
incision is necessary. If, through improper treatment, the chronic is 
converted into an acute abscess, free direct incision must be employed. 
Friction sometimes changes a chronic into an acute abscess. It some- 
times happens in unhealthy constitutions, that, after injuries or ampu- 
tations, very extensive collections of pus take place under the periosteum ; 
and in some forms of phlebitis collections of purulent matter form without 
being preceded by accident or amputation; sometimes they happen as 
sequelae of fever. They almost always prove fatal ; yet, if the patient 
be healthy, he may recover after necrosis of the bone. 

INTERNAL SUPPURATION. 

Of this there are four varieties : namely, diffuse acute internal 
suppuration ; limited acute internal suppuration ; chronic internal sup- 
puration ; and scrofulous tubercular abscess of bone. 

I. DIFFUSE ACUTE INTERNAL SUPPURATION, OR DIFFUSE ACUTE 
INTERNAL ABSCESS. 

This follows as an effect of acute ostitis, of which it has the local and 
constitutional symptoms. If the patient do not sink under the disease, 
rigors and hectic fever supervene, and sooner or later there is an indis- 



294 



SUPPURATION IN BONE. 



tinct undulation or fluctuation beneath the periosteum and the super- 
imposed soft tissues which become involved. This disease depends upon 
diffuse inflammation within the bone, the matter occupying in the short 
bones the cancellated structure, and in the long cylindrical bones the 
canals, there being no tissue or sac to circumscribe it. The purulent 
matter destroys the cancellated structure, and some parts of the bone 
become very much absorbed. The canals for the transmission of vessels 
become enlarged, and through, them and the apertures formed by the 
absorption of portions of the bone, the matter makes its way to the 
surface. 

Treatment. — This is at first the same as in acute ostitis, and should 
be as decided as the circumstances of the case will admit. As soon as 
fluctuation is present, recourse must be had to free direct incisions. 
When hectic fever supervenes, the treatment must be tonic. 

II. LIMITED ACUTE INTERNAL SUPPURATION, OR LIMITED ACUTE 
INTERNAL ABSCESS. 

This usually takes place in the cancellated heads of the long bones, 
frequently in the head of the tibia, sometimes in its shaft, and sometimes 
in its under extremity, in persons about or beyond the middle period of 
life, who are exposed to cold and night air. 



Fig. 86. 



Fig. 87. 




Symptoms. — The principal symp- 
tom is most excruciating pain. This 
has been found in some cases to be 
constant, and in others to be slight, 
or amounting only to uneasiness 
during the day, but in all liable to 
severe nocturnal exacerbations. It is referred by the patient to a par- 
ticular spot, and is attended with a degree of throbbing and a sensation 




SUPPURATION IN BONE. 



295 



of weight. As the disease advances, tenderness and pain are experienced 
when pressure is applied to the soft tissues and the part of the bone ex- 
ternal to the disease. After some time the skin becomes red and slightly 
hot, but there is no swelling. The symptoms are aggravated by motion 
of the limb. 

State of the Parts. — After the disease is fully formed, on making a 
section of the bone, there is observed a cavity or sac in its interior, 
having a distinct bony encasement. The interior of the cavity is lined 
with a vascular membrane, from which the exudation takes place which 
is transformed into pus. A lower degree of inflammation extends to 
the textures external to the bony encasement. In the museum of St. 
George's Hospital, there are several very beautiful and interesting spe- 
cimens of this disease. 

Treatment. — Sir Benjamin Brodie has the merit of having proposed 
the proper treatment, which consists in making a crucial incision of the 
soft parts, exposing the bone, and by means of a trephine sawing out 
a portion of it, so as to allow of the evacuation of the matter. Sir 
Benjamin Brodie has treated cases successfully in this way; Mr. Liston, 
in his " Elements of Surgery," records a very instructive case, in which 
the same practice was followed by the desired result ; and many other 



cases have been treated with equal success. 



Figs. 



89, represent a 



Fig. 88. 



Fig. 89. 





case in which the matter made its way to the surface, by its own efforts ; 
but, from the firm nature of the new bony encasement which surrounds 
the matter, this is a result which can seldom be looked for. 



III. CHRONIC INTERNAL SUPPURATION, OR CHRONIC INTERNAL ABSCESS. 

Symptoms. — These, both local and general, are the same as those of 
chronic ostitis, although sometimes at first they indicate acute ostitis. 
Swelling of the 'bone soon occurs, and if the strength of the patient 
holds out, so that the disease runs its course, an indistinct undulation 
or fluctuation, depending upon the thin state of the bone, is at last per- 
ceptible to the touch. The constitutional symptoms are ultimately 
those of hectic fever. 



296 SUPPURATION IN BONE. 

State of the Parts. — As the name of the disease indicates, matter is 
formed, and it is contained in an indistinct cyst. "The result of the 
pressure of the abscess is to cause an absorption of the cancellated 
structure, and in this way the space for the increase of the abscess con- 
tinues to be enlarged." The matter is thin and unhealthy, and is 
mixed with the debris of the bone. The cancellated tissue of the bone 
is dilated, and the integuments over the bone become inflamed. 

Treatment. — This consists in free direct incision through the soft 
tissues and the shell of bone, which is, in consequence of disease, gene- 
rally divisible by a strong scalpel. After the evacuation of the matter, 
it is advisable to inject sulphate of zinc lotion into the interior of the 
bone, to employ gentle lateral compression and support, and at the same 
time to enjoin rest, and adopt judicious measures for supporting the 
general strength. 

IV. SCROFULOUS TUBERCULAR ABSCESS OF BONE. 

Symptoms. — This affection which, as the name indicates, is met with 
in persons of a scrofulous habit, is at first characterized by a sense of 
weight and uneasiness in the diseased part, not amounting to pain. 
This sensation is referred to a particular part, and is increased by 
pressure and by motion, and sometimes by the heat of bed. Enlarge- 
ment of the osseous tissue takes place, followed by oedematous swelling 
of the soft parts, and the integument presents a bluish colour. In the 
suppurative stage the uneasiness is changed into actual pain, and the 
enlargement increases more rapidly. The matter, sometimes, makes 
its way to the surface, in which case, a swelling with fluctuation will be 
perceptible. On being discharged, it presents the ordinary characters 
of such collections in scrofulous habits ; and the cavity has no tendency 
to heal, but continues to throw out an offensive discharge. Such col- 
lections, instead of making their way to the surface, frequently open 
into the neighbouring articulation ; and in that case there is great 
increase of pain, and of the other local symptoms, together with pretty 
decided symptoms of irritative fever, which soon change to those of the 
hectic type. Except when the disease opens into an articulation, it is 
not accompanied by any strongly-marked symptoms of inflammatory 
fever ; but in all cases it, sooner or later, gives rise to hectic fever. 

State of the Parts. — The cancellated structure of the bone, especially 
of the heads of the bones, is filled with scrofulous, or tubercular matter. 
This substance first fills the cells, and by the accumulation of it, the 
cancellated tissue of the bone becomes absorbed, and its place occupied 
by the deposit. The morbid deposit may be the result of previous per- 
version of nutrition, or the change of liquor sanguinis exuded in conse- 
quence either of congestion or a slight grade of the inflammatory process. 
The change of the liquor sanguinis into scrofulous or tubercular deposit, 
is believed to depend on the constitution or inherent composition of the 
exudation. The constitution is supposed to be determined by that of 
the blood ; and such being the case, the importance becomes evident of 
attending to the nature of the food, of promoting the proper performance 
of the functions of the digestive organs, and of guarding against every- 
thing calculated to operate unfavourably on the composition and proper- 



ABSORPTION OF BONE. 297 

ties of the blood. In its progress, the disease comes to be accompanied 
with a degree of inflammation, which proceeds to suppuration. 

Treatment. — This local affection is very much influenced by the state 
of the general health, which therefore requires to be particularly 
attended to through all its different stages. The formation of the 
tubercular deposit in the cancellated structure of the bone is the first 
deviation from its sound condition. The conditions in which that for- 
mation is most apt to take place, are believed to be the scrofulous 
diathesis, together with a weak state of the general health. It is often 
found in persons of that habit who have been confined to situations 
where the air is impure, cold, or damp ; who have lived on a diet not 
sufficiently nutritious ; who have not enjoyed regular exercise and expo- 
sure in the open air ; or who have been subjected to any particular 
cause of debility. If the presence of the deposit be suspected, the 
endeavour must be made to limit its extent, and to delay the suppuration 
by removing the patient from the influences which excite unhealthy 
secretion. For that purpose free exposure in the open air, generous 
diet and the use of such medicines as from the particular state of the 
patient are most likely to improve the general health, must be strictly 
enjoined. Tonic medicines, and more especially the preparations of 
iron, are useful ; but as permanent strength can be communicated only 
by the proper assimilation of nourishment, those remedies should be used 
which, from the particular state of the patient's health, are most likely 
to fit the digestive organ for the reception and proper digestion of food. 
Of all remedies cod-liver oil is the most valuable in this, as well as in 
other scrofulous affections. Limitation of the tubercular deposit, and 
prevention of suppuration are obviously paramount indications. When 
suppuration does take place, the pain should be mitigated by fomentations 
and rest of the affected part, and the matter should be evacuated as 
soon as its presence is detected. Sometimes counter-irritation by means 
of a blister gives some relief from the pain ; but local depletion forms no 
part of the proper treatment of this affection, as it would only diminish 
the general strength without helping to remove the local disease. 

General Suppuration will be considered when treating of Necrosis. 

ABSORPTION OF BONE. 

This may take place without any inflammation, and therefore without 
being accompanied by the formation of purulent matter, or of any se- 
cretion caused by inflammation. Of absorption of bone without inflam- 
mation there are two distinct varieties, namely, the continuous, and the 
interstitial. 

Continuous absorption is the name given to that process by which a 
portion of bone is completely removed without inflammation. The con- 
dition under which this process takes place, is when a bone is subjected 
to gradual and moderate pressure, without the admission of the air to 
the compressed part. If there be admission of air to the compressed 
part, or if the pressure be very severe, inflammation will be induced, 
and purulent matter formed, and the process by which the bone is re- 
moved is then called ulceration. If the pressure be gradual and mode- 
rate, and if the air be excluded, the effect of the pressure is to stimu- 



298 ULCERATION OF BONE. 

late absorption without inflammation, and the . process by which the 
bone is removed is then called continuous absorption. By this process, 
in some instances, a large excavation is formed in a bone, and in others, 
the continuity of a bone is so interrupted that it becomes divided into 
two portions. Examples of this singular change are met with in cases 
of tumours, aneurism, or chronic abscess. The gradual compression 
caused by these diseases sometimes produces a depression in a bone, 
and in some instances, as for example in aneurism within the chest ma- 
king its way to the surface, portions of some of the ribs are so complete- 
ly removed that their continuity is entirely interrupted. The only 
mode of treatment which can stay the progress of continuous absorption, 
is to remove the exciting cause, by curing the disease from which it 
arises. 

Interstitial absorption may affect either a part or the whole of a bone. 
In the former case it is indicated by dull uneasiness or a sense of fa- 
tigue, or aching of the part, increased very soon to actual pain on exer- 
cise ; by slight oedema of the superimposed soft parts, which is also in- 
creased by exercise ; by lividity from passive congestion, and sometimes 
also by coldness of the integument. This form of interstitial absorption 
often occurs in the tarsus and metatarsus, and in the carpus and meta- 
carpus, and frequently terminates in caries. In this disease the lami- 
nated portion of a bone is converted into cancellated texture, and the walls 
of the cells become thinner, so that the cells appear very large. The 
surface of the bone also presents a very porous appearance. The treat- 
ment consists in attention to every measure likely to improve the gene- 
ral health, combined with rest of the part affected, and the constant 
use of gentle counter-irritation, while the symptoms continue. After 
the removal of the local symptoms, gentle support of the part is often 
found to be grateful to the feelings of the patient. 

Interstitial absorption affecting the whole of a bone is often met with 
in diseases which affect the articular extremities of the long bones. 
There is a wasting and absorption of the bone as well as of the other 
tissues of the limb. To such an extent does this absorption sometimes 
take place that the shell of the bone becomes extremely thin, and the 
cancellated structure uncommonly open, so as to present the appearance 
of large cells with very thin walls, and in some parts the cancellated 
structure is entirely removed. 

The removal of the local disease which is the exciting cause of this 
affection, and the improvement of the general health together with the 
restoration of the limb to the performance of its usual movements, are 
the only means by which the unnatural absorption can be checked, and 
the healthy communication of nutrition to the bone be restored. 

ULCERATION OF BONE, OR THE SIMPLE AND TRACTABLE ULCER 

OF BONE. 

Some writers use the terms ulceration and caries synonymously. By 
ulceration we mean that condition of bone in which there is loss of sub- 
stance, together with suppuration, but in which the ulcer has a tendency 
to heal. In caries, on the contrary, while there is loss of substance, to- 
gether with suppuration", there is so far from being any tendency to 



ULCERATION OF BONE. 299 

heal, that healing is very difficult to accomplish. This difference as to 
the tendency to heal depends on the different conditions of the bone at 
the surface of the affected part. Mr. Liston observes, " It may tend to 
prevent confusion of the two different morbid states, if we confine the 
term ulceration to suppuration in and absorption of bone, whilst the ves- 
sels retain a considerable power of action, throw out new matter, and 
procure a reparation of the breach; and this condition of the osseous 
tissue exists when the disease is situated on the surface of the bone, and 
when it has been produced by an external cause. On the contrary, the 
term caries will denote that particular kind of ulceration in which repa- 
ration is hardly attempted by nature, and is with difficulty obtained by 
the most active interference ; and this disease will be most generally 
found to affect the cancellated structure." 

Ulceration is caused by pressure, combined with inflammation. In a 
portion of bone, excluded from the air, pressure alone, unless carried 
to such an extent as to excite inflammation, is not sufficient to produce 
ulceration, but may cause continuous absorption. Some writers there- 
fore say, that pressure is the predisposing, and inflammation the exciting 
cause. Pressure may be either external or internal : examples of the 
latter are furnished by suppurative ostitis taking place within a bone, 
when the matter may make its way to the surface by ulceration ; and 
of the former many examples are met with, of which one of the most 
frequent is, pressure on the surface of the bone by collections of matter 
forming in consequence of inflammation of the superimposed soft tissues 
in the vicinity. 

Ulceration of bone is characterized by an ulcer of healthy ap- 
pearance. Examination with the probe is sufficient to show the nature 
of the disease. The bone itself, which supports the ulcerated portion, 
is not diseased, differing in this respect from the state of the bone in 
caries ; for while there is in each disease the removal of part of a bone 
in consequence of inflammation, in a state of simple ulceration the por- 
tion of bone forming the surface of the part retains its natural compact- 
ness and firmness ; but the portion forming the surface of a carious part, 
and to some depth below, is in a state of interstitial absorption. The ac- 
tion of the vessels is, consequently, very much weaker in the latter case 
than in the former, and hence arises the difference, as regards the ten- 
dency to heal, between the two diseases, which in other respects are 
very similar. Simple ulcer of bone is healed by the bone forming gra- 
nulations, which, though soft at first, are soon converted by the deposi- 
tion of earthy matter into bone. By these granulations the surface is 
to a certain extent elevated, and the edges of the ulcer are lowered by a 
process of absorption, so that the parts are brought nearly to a level 
with each other. Owing to the inelastic nature of the bone, the chasm 
cannot be diminished by the centripetal movement, as in an ulcer of 
the soft parts ; but it is brought nearly to a level, as has just been de- 
scribed, by the r'ounding off by absorption of the edges, and the filling 
up of the centre by osseous granulations. The soft parts coalesce with 
the granulations, and a fibrous membrane is formed over the latter, on 
which a cicatrix, having a depressed, white, and firm appearance, is at 
last developed. This is the appearance of the cicatrix when the ulcer 
of the bone is perfectly healed, and the cicatrix adheres to the bone ; 



300 CARIES. 

but occasionally a cicatrix is formed before the. bone has healed, and 
then it does not adhere to the bone, but is elevated, livid, soft and 
painful, and is usually soon destroyed, exposing again the ulcer of the 
bone. 

Treatment. — The constitutional treatment consists in the use of all 
prudent means for improving the general health, and maintaining the 
strength, so as to promote the energy of repair ; and the local, in the 
removal of the exciting cause and the employment of rest, a proper 
attitude, simple water-dressings, or medicated, if it be necessary to 
stimulate, together with gentle support by bandages. 

CARIES. 

Caries is derived from xetp&, to abrade, and is employed to denote a 
particular disease of bone. The terms, caries and necrosis, were by the 
older writers used indiscriminately, although they are two separate and 
distinct diseases. In caries, part of a bone is removed by the action of 
the absorbents causing a chasm ; in necrosis, part of a bone completely 
dies; in caries there is very little, in necrosis a very great, effort of 
nature to form new bone. 

" The points of resemblance," Professor Samuel Cooper writes, " be- 
tween caries of bone and ulceration of the soft parts are striking ; each 
affection is preceded by inflammation ; each is attended with the forma- 
tion of matter ; each may be followed by the production of granulations ; 
each may arise from local or constitutional causes ; and each may be 
combined with the total extinction of vitality in certain points of the 
textures affected. Thus precisely in the same way as we often see 
ulceration and sloughing exhibited together in the soft parts, we also 
frequently find caries and necrosis prevailing together in the bones. 
Some portions of the osseous texture seem to perish and to be detached 
from the living parts of the bone, while in other places caries is making 
its attack and producing its usual effects." Caries generally affects the 
spongy extremities of the long bones, especially the ends of the femur 
and tibia, the bodies of the vertebrae, the bones of the tarsus and carpus, 
the sacrum, the sternum, the patella, the lower jaw, and occasionally the 
bones of the cranium. Necrosis, on the contrary, attacks the compact, 
lamellated or firm tissue of bone. Sometimes, though rarely, caries does 
present itself in the lamellated tissue of bone ; but before this takes 
place the bone loses its compact appearance. 

Causes. — These may be divided into external and internal. The 
principal external causes are a violent blow, or a wound, and more 
especially if it be combined with a bruise, as in a gun-shot wound affect- 
ing a bone, atmospheric changes, extensive injury of the periosteum, 
continued pressure by long maintenance of one position (as in a tedious 
illness, or fever, when caries of the sacrum is apt to take place, or of 
the trochanter major of the femur, or sometimes of both), suppuration 
or ulceration of the soft parts in the neighbourhood, or in short, any 
external injury or condition capable of exciting inflammation and ulce- 
ration of bone. 




CARIES. 301 

The principal internal causes are certain states of constitution, and 
more especially that condition which 

we denominate scrofulous, that which Fl s- 90 - 

is the consequence of infection from 
the venereal poison, and that which 
results from the free or injudicious use 
of mercury. These conditions of sys- 
tem may be considered predisposing 
causes ; but they seem also capable of 
acting both as predisposing and ex- 
citing causes ; at all events, when any 
of them have produced the predisposi- 
tion, caries makes its appearance from 
very slight external causes, and in 
many instances without any known 
exciting cause at all. The worst forms 
of caries are those which take place 
when all the above conditions meet 

together ; that is, in a scrofulous person infected with syphilis, whose 
constitution has been affected by mercury. Other internal causes, pre- 
disposing to caries, though not so powerfully, are the conditions of con- 
stitution which exist in scurvy, rheumatism, and gout. Scrofulous 
caries, syphilitic caries, scorbutic caries, rheumatic caries, and arthritic 
caries, are names by which some of the above-mentioned forms of this 
disease are distinguished. The various forms of caries differ from each 
other in the parts of bones in which they are most frequently found. 
Scrofulous caries, the most frequent form of all, usually attacks the 
spongy texture of bones, as the bodies of the vertebrae, the spongy ex- 
tremities of the long bones, and the tarsal and carpal bones, beginning 
in these parts by the deposition of tubercular matter in their cancellated 
structure ; which deposition is succeeded by inflammation, ending ulti- 
mately in caries. Syphilitic caries, which is the next in frequency, 
attacks the compact parts of the bony structure, such as the dense or 
hard part of the tibia, the compact part of the ulna, and the bones of 
the cranium. The rheumatic, like the scrofulous, is most frequently 
met with at the joint ends of the long bones ; but it arises from inflam- 
mation of the ligaments and synovial membrane, extending sometimes 
to the articular surface itself. The arthritic, like the rheumatic, takes 
place in the region of the joints, but seems to prefer the external sur- 
face of the bone, and is generally preceded by a kind of exostosis in 
which the caries take place, and by the formation of arthritic concre- 
tions in the neighbourhood. 

Phlegmonous erysipelas, suppression of customary discharges, and 
the sudden repelling of profuse eruptions of the skin, have been known 
to cause caries. 

Fig. 90. Caries of bones of cranium and face, producing free communication bet-ween 
the mouth, nose, orbits, frontal sinuses, and cranium. Disease commenced by ulcera- 
tion of soft palate with tubercular syphilitic eruption. From the history it appears 
that the patient had been subjected to the injudicious use of mercury. From a prepa- 
ration in my museum. 



302 CARIES. 

Symptoms. — Caries being a result of inflammation, is preceded by 
ostitis, either acute or chronic, the symptoms of which will vary to a 
certain extent according to the nature of the ostitis, as will be readily 
understood from what has been previously stated regarding different 
varieties of inflammation of bone. Sooner or later the soft parts conti- 
guous to the bone participate in the inflammation ; and if the affected part 
be situated near the surface, a swelling is in some little time observable. 
This swelling is firmly adherent to the bone, and the skin over it be- 
comes red, tense, and painful. It ultimately becomes soft, indicating the 
presence of suppuration ; and if opened, or allowed to proceed without 
int Deference, the matter which escapes from it is thin and offensive, and 
rarely presents the characters of well-formed pus. After the discharge 
of the contents of the abscess, either spontaneously or by an opening, 
the cavity does not heal ; but continues to discharge matter which tar- 
nishes a silver probe, is thin, ichorish, and offensive, and has that pecu- 
liar foetor by which, without any other symptom, it is possible to deter- 
mine with considerable certainty that it proceeds from a part connected 
with a diseased bone. The foetid matter is loaded with a considerable 
quantity of phosphate of lime. The aperture of the abscess contracts 
and takes the form technically called fistula, and throws out from its 
edges granulations, which are spongy, painful, and very apt to bleed on 
being touched with the probe. The granulations project beyond the 
margin of the aperture, and the surrounding integument exhibits a livid 
hue. If a probe be introduced into the aperture, the bone is found to 
be rough and denuded, its surface irregular, and the osseous texture so 
much softened, that, with the slightest pressure, the probe will sink 
into it to a considerable distance. The impression communicated to the 
surgeon on making an examination with the probe, is not precisely the 
same in every instance of caries, the condition of the bones being diffe- 
rent, as was before mentioned, in different forms of the disease. In 
caries of deep-seated bones, as for example, in scrofulous caries of the 
vertebrae, the accompanying collection of matter exhibits the characters 
of a chronic, instead of those of an acute abscess. I have often been 
struck, in cases of scrofulous caries of the vertebrae and of other bones, 
with the fact that in many instances, patients would scarcely admit that 
they had experienced any pain in any stage of the disease. The con- 
stitutional symptoms vary, in the first instance, according to the nature 
of the inflammation producing the caries, and the state of the patient's 
system at the time. In scrofulous caries the patient exhibits the stru- 
mous habit, and in general symptoms of scrofulous cachexy soon be- 
come very apparent. During the suppurative stage of caries, and 
more especially in cases where the caries communicates with an articu- 
lation, irritative fever comes .on, but soon gives place to hectic fever, 
by which in unfavourable cases, such as when the caries is in inaccessi- 
ble situations, the disease proves fatal. In some instances the only con- 
stitutional symptoms observable are those of hectic fever. 

State of the Parts. — The bone does not in every instance of caries 
present the same appearance. If the varieties in the state of the bone 
be made the basis of arrangement, it may be said that caries may exist 
in one or other of the three following forms : — 



CARIES. 



303 



Fig. 91. 



1st. That in which there is a regular and distinct excavation of a 
portion of bone. The extent of the disease, however, is by no means 
indicated by the extent of the excavation. 

2d. That in which the outer encasement or lamella of bone gives way, 
and the cancellated structure becomes carious without any distinct 
excavation. In this form the destruction by ulceration is very superfi- 
cial, being confined to the outer encasement, but the alteration by 
interstitial absorption in the cancellated structure is very extensive. 

3d. That in which the bone has the appearance of having been 
perforated in innumerable places, termed the worm-eaten caries. This 
condition is occasionally met with in the external surface of a long bone 
affected with the first form of caries, the perforations being found in the 
outer encasement in the neighbourhood of the excavation ; but the best 
examples of worm-eaten caries I have 
seen, have been in the cranium. In 
one admirable preparation of this form 
in my possession, the whole of the 
upper part of the cranium is occupied 
with innumerable perforations, and in 
another, the bones are in some parts 
bored in hundreds of places, and in 
others, affected with necrosis. In the 
first mentioned specimen the bones 
have in every respect, with the excep- 
tion of the perforations, a healthy ap- 
pearance, no traces whatever being 
observable of any other disease, or of 
any deviation from the natural and 
sound condition of the osseous struc- 
ture. In some other specimens of this 
form of caries, I have been struck with 
the absence of any apparent traces of change of structure in the osseous 
substance, a circumstance in which this form seems occasionally to differ 
from the other two varieties. In the second specimen mentioned above, 
the disease was in a girl twelve years of age, and was occasioned by 
a blow. 

In the first form of caries there may be said to be three different 
states. First, a part of the bone, where the excavation exists, is 
removed by ulceration. Second, the part which forms the surface of 
the carious portion is affected to a considerable depth by interstitial 
absorption, in consequence of which its lamellae are so thin, and its 
circulation so feeble, that a healthy action rarely takes place. Its 
circulation is sufficiently weakened to create a great obstacle to the 
formation of healthy granulations, and yet not so as generally to deprive 
the part of all vitality and produce necrosis. It is in the presence of 
this interstitial 'absorption, that caries differs from simple ulceration. 
Third, beyond the interstitially absorbed part, the bone is often rendered 
preternaturally dense by the secretion of new osseous matter into its 
cancellated structure ; and its external surface is, from the same action, 
covered over with nodules or spicula of new bone at the parts where 




30-1 CARIES. 

there is a sound and firm bone underneath. In the second form the 
ulceration is very superficial, but the interstitial absorption very deep 
and extensive, and sometimes, as some specimens of it in the tarsal 
bones in my own collection demonstrate, it extends almost through the 
whole of the bone. When it is very extensive, the attempts at the 
formation of new bone in the neighbourhood of the interstitially absorbed 
part are very feeble, and in many instances, no traces whatever of such 
an action can be discovered. Although the interstitial absorption 
frequently extends to a great depth, it is also certain, on the other hand, 
that occasionally it is very superficial, and the very limited extent of 
change of structure is sometimes remarkably disproportioned to the 
severity and obstinacy of the symptoms. Caries is in every instance a 
consequence of inflammation, and it may or may not be accompanied 
by the deposition of tubercular matter in the cancellated structure. 
When there is a deposit, it may present any of the varieties of appear- 
ance mentioned in the section on suppuration of bone, and, as is there 
stated, it may not be a product of inflammation, but a consequence of 
previous perversion of nutrition in a person of a scrofulous constitution. 
In some instances this deposit is limited to a small part, in others it is 
very diffused ; in some it is contained in cells of the cancellated struc- 
ture, and in others, as many of my own preparations evidence, it seems 
to occupy the whole space included within the shell of the bone, and 
scarcely any traces of the cancellated structure remain. When the 
deposit is present, the attempts to secrete new bone in the neighbourhood 
of the part involved in the caries seem to be in general extremely feeble, 
and such cases are in consequence exceedingly unpromising. Professor 
Syme remarks, that after maceration a carious bone looks as if it had 
been burned, being harder, whiter, and more brittle than natural. I 
have sometimes been struck with this brittleness and hardness after long 
maceration and drying in instances where, while the bone remained in 
the body, it felt so extremely soft, that a probe could with the slightest 
pressure, and almost without experiencing any resistance, be made to 
sink through it in any direction. 

DIFFERENT MODES OF SPONTANEOUS CURE. 

Nature sometimes accomplishes a cure of caries in one or other of the 
three following ways : — 

1st. By a complete change in the action of the diseased part, in con- 
sequence of which granulations form, which are converted into bone ; 
and a deposit of osseous matter thus taking place, the cavity is filled 
up in the same manner as a simple ulcer of bone. 

2d. By a process of exfoliation, by which the whole of the ulcerated 
portion of bone is thrown off, together with the parts rendered weak by 
interstitial absorption. 

3d. By anchylosis, or that process in which sufficient new callus or 
bone is thrown out to ossify the articulation. 

Treatment. — In all inflammations of bone, such treatment should be 
adopted, as will be most likely to prevent them from terminating in 
caries. With this view local and general depletion, though necessary, 
must not be carried too far, as the consequent debility predisposes to 



CARIES. 305 

caries ; and as the danger of its occurrence is likewise increased by the 
interstitial absorption arising from the free use of mercury, this medi- 
cine, if ventured upon at all, must be exhibited with great caution. 
Simple ulceration of the bone should be healed as speedily as possible ; 
unnecessary irritants should never be employed ; abscesses must be 
opened, and " effused pus ought never to be allowed to remain on the 
surface of the bone, but must be early evacuated." If caries be the 
consequence of scrofula or syphilis, it is not so much under the influ- 
ence of local treatment as of the proper constitutional treatment for 
those diseases. 

When caries is fairly established, the treatment varies according to 
the situation of the disease. On this account, the situations of caries 
are divided into those accessible, and those inaccessible, to the surgeon. 
To the latter class belong caries of the vertebrae, of the hip-joint, and 
of the knee. 

In accessible caries, unless there be great reason to hope for a spon- 
taneous cure by one or other of the three processes already described, 
the best treatment is the complete removal or excision of the diseased 
portion of bone. On no account, however, should any attempt at re- 
moval be made, while acute inflammation exists in the bone or the 
neighbouring tissues. Although the carious part could be excised under 
such circumstance, the operation, instead of being succeeded by a heal- 
ing process, would, by increasing the inflammation, cause extension of 
the disease. With regard to the extent of removal, suffice it to say, 
that a firm, sound base should be left ; the whole of the ulcerated and 
interstitially absorbed portion of bone should be removed. The instru- 
ments most serviceable for the excision or removal of the diseased part 
vary according to the situation. In some instances, a scoop may be 
sufficient ; in others, trephines, saws, knives, or the cutting forceps, are 
required. After removal has been effected, the wound should be treated 
in the manner proper for a simple ulcer of bone. If the caries has been 
in parts which form an articulation, the bones must, after the operation, 
be kept in apposition, and at perfect rest. It sometimes happens that 
a patient cannot be persuaded to submit to the operation of excision. 
Under such circumstances, the most advisable procedure is to destroy 
the diseased part by means of the chloride of zinc, made into a paste, 
or the red oxide of mercury in powder. For my own part, I prefer the 
former escharotic, but they both answer very well, and are not, like 
acids or liquid escharotics, liable to the objection of sinking deep into 
the substance of the bone, and thereby causing extensive and unneces- 
sary destruction, or of increasing the disease. The escharotic must be 
employed so as to insure the object of its application, namely, the com- 
plete destruction of the diseased part ; and after it is taken off, some 
lint should be introduced into the wound, and poultices employed for 
alleviating the pain, and promoting the separation of the destroyed 
parts. When removal has taken place, the treatment proper for a sim- 
ple ulcer of bone should be adopted. It sometimes happens, that after 
the surgeon has removed, by instruments, as much of the bone as seems 
advisable, a part still remains of a suspicious appearance, yet not so 
circumstanced that it would be judicious to remove it by excision. 

20 



306 NECROSIS. 

Some surgeons recommend that, in such circumstances, the suspected 
part should be destroyed by one of the escharotics above mentioned ; 
and the practice is often followed by the most satisfactory results. At 
one time the actual cautery was much employed for the destruction of 
carious parts. In regard to this practice I cannot do better than quote 
the language of Mr. Liston. " The application of the actual cautery 
may be by some considered necessary ; at one time I employed this re- 
medy very extensively in caries, and occasionally with very good success. 
I have since, however, been led to change my opinion, and am now 
inclined to prefer the potential cautery. By the application of the red- 
hot iron, the diseased portion is destroyed effectually, but at the same 
time, the vitality of the surrounding parts is often very much weakened, 
and their power of reparation diminished, so that they are incapable of 
assuming a sufficient degree of action for throwing off the dead part ; 
their action being increased, while their power is diminished, they may be- 
come affected with caries, and thus, instead of being arrested, the original 
disease will either be increased, or extensive necrosis may take place." 

When the caries is in situations inaccessible to the surgeon, that is to 
say, where it does not admit of excision, as in the hip-joint, the knee- 
joint, and the vertebrae, the surgeon should endeavour to obtain anchy- 
losis. The most important means for this end are, — attention to every 
measure, judicious in the condition of the patient, for maintaining the 
general health and strength, perfect rest of the affected parts, and the 
employment of counter-irritation. If the vertebrae be the subject of the 
disease, the spine must be kept at rest, and in a reclining position, so as 
to remove from it the superincumbent weight. The treatment, however, 
of caries in that situation will be particularly described in the section on 
diseases of the spine. If the knee-joint be the part affected, the limb 
ought to be extended, and kept in that attitude by means of a flat con- 
cave splint, applied behind the joint; if the disease be in the hip-joint, 
the trunk, thigh, and leg ought to be preserved in a straight line with 
each other. Counter-irritants are also used with advantage. Those 
which are most generally preferred, and which are found to prove most 
beneficial, are blisters, small issues kept open by the occasional applica- 
tion of potassa fusa, and setons. Experience seems to show that, in 
some situations, some of the means for producing counter-irritation are 
employed with more advantage than others ; but this will be more fully 
explained in the description of the diseases of the joints and of the 
spine. One important point, however, should always be kept in view, 
whatever be the application employed ; and that is, not to produce such 
a discharge as would affect the general strength ; for the maintenance 
of the patient's general health is fully as important as keeping up coun- 
ter-irritation. When a collection of pus is perceptible, it must be opened 
by a small orifice in the most dependent part, and gentle pressure em- 
ployed to keep the sides of the abscess in apposition. 

NECROSIS. 

This term, derived from vt*go», to put to death, is now, by the consent 
of surgeons, employed to denote the dead condition of bone. In the 
soft tissues the state corresponding to necrosis, is called mortification. 



NECROSIS. 307 

Louis, who was the first to restrict the application of the term necrosis 
to death of bone, applied it only to death of the entire thickness of 
the bone, and not of the external or internal part, of which, however, 
there is frequently complete death, followed by removal. The bones 
most liable to necrosis are, the tibia, the femur, the lower jaw, the cla- 
vicle, the fibula, the humerus, the radius, and the ulna ; occasionally, 
also, the bones of the cranium are subject to it. While caries, as has 
been already noticed, is found principally to affect the spongy portions 
of bone, necrosis, for the most part, attacks those bones which are of a 
firm, compact texture. It may occur at any period of life, and in both 
sexes, yet we more commonly meet with it in young persons from twelve 
to eighteen years of age; but when it affects the lower jaw, it is seldom 
before the thirtieth year. 

The causes of necrosis may be divided into external and internal. Of 
the former are severe contusions of bone ; bad compound fractures ; the 
pressure and irritation of tumours, of abscesses, or of a musket ball ; 
acute ostitis ; or the application of strong concentrated acids. It fre- 
quently results also from severe cold, and occasionally from burns. 
Destruction of the medullary membrane is found, by experiment on the 
lower animals, to produce necrosis. The internal causes are such as 
affect the bone through the medium of the constitution. Scrofula, 
syphilis, and the baneful influence of mercury on the constitution, seem 
to produce a considerable tendency to necrosis. 

If necrosis take place without any known exciting cause, it is said to 
be idiopathic ; if it be the consequence of a compound fracture, it is 
called compound ; if it be caused by violence, as by a blow, it is deno- 
minated traumatic. 

Varieties of Necrosis. — The different forms or varieties of necrosis 
are by some arranged into two, by others into three, separate and dis- 
tinct species. We shall, however, consider four varieties. 

1. That form which generally occurs in a person of a scrofulous habit 
of body, and in which the short bones are affected, as those of the tarsus, 
metatarsus, carpus, or metacarpus. 

2. That form in which there is death only of the outer lamella, that 
is, in which the disease is superficial, and does not extend through the 
whole thickness of the shell of the bone. This form sometimes presents 
itself in the flat bones, as the scapula, and the bones of the cranium. 

3. That form which destroys the internal part of a bone, and in which 
the cortex or outer shell is not affected. This is by some writers called 
internal necrosis. 

4. That form, in which the whole thickness of a bone perishes. The 
three last-mentioned forms may be distinguished from each other by the 
names of external, internal, and general necrosis. 

Symptoms of the First Form. — An indolent swelling first presents 
itself, unattended with much pain or constitutional disturbance. The 
swelling is at first hard, after some time oedematous, and at length 
attended with fluctuation inconsequence of a thin ichorish fluid collected 
in the part. If a probe be introduced, the bone will be felt to be rough, 
and divested of its periosteum. The aperture has little tendency to 
heal. In consequence of the continued irritation, hectic fever is pro- 



308 NECROSIS. 

duced. As in this form nature makes no attempt at reproduction, re- 
moval of the limb is absolutely necessary. 

Symptoms of the Second Form. — These, in the first instance, depend 
upon the cause of the disease, which is often an acute abscess, or acute 
periostitis, or acute ostitis. A small abscess occurs in the soft parts, 
which, if left to nature, discharges itself. If a probe be introduced, the 
bone is found to be bare, and a part perhaps loose. The aperture does 
not heal until the sequestrum or dead portion of the bone is removed, 
but becomes what is technically called a fistula. The separation of the 
sequestrum is effected by the absorbents taking up the next layer of 
bone, and bears an analogy to that process by which sloughs of the soft 
parts are detached. The aperture now heals by granulation in the 
same manner as in simple ulcer of bone. This form of necrosis has by 
some writers been called exfoliation. 

Symptoms of the Third Form. — There is most excruciating pain, 
supposed to arise from the resistance offered by the cortex or outer 
lamella to the swelling of the inflamed part. The inflammatory fever 
is often so high as to prevent the patient from obtaining repose. The 
swelling is exceedingly hard and diffused, depending on the swollen con- 
dition of the bone. It also continues for a very long time, before any- 
thing unnatural is observed in the soft parts ; but in them an abscess 
gradually forms. The pain is not aggravated, as in other forms of this 
disease, by pressure or handling of the limb. The other symptoms 
nearly correspond with those of general necrosis. 

Symptoms of the Fourth Form. — In this form of the disease the arti- 
culatory extremities are not generally involved. Pain of a most excru- 
ciating, girding, bursting character is one of the earliest symptoms. 
The pain is constant, and is followed by a swelling, which is diffused, 
presenting no distinct bounds, but generally greater about the middle of 
the limb than elsewhere. The character of the swelling at first is 
doughy and elastic, by reason of the effusion between the periosteum 
and the bone, and the thickening of the periosteum itself. This is 
followed by a soft swelling, which is less diffused, and ultimately 
attended with fluctuation, and presents the ordinary local symptoms 
of an acute abscess, which, if permitted, finds an outlet for itself. 
If a probe be introduced after the contents of the abscess are dis- 
charged, the bone will be found to be bare, and ultimately becomes 
loose. The pus itself is thick, yellow, and of a healthy, purulent cha- 
racter. After the evacuation of the abscess, there is some diminution 
of the pain ; but the opening has no disposition to heal, and presents 
the appearance which is technically called fistula. After the matter is 
discharged, there is but little subsidence of the swelling, which is gene- 
ral, presenting no distinct "boundary, and of a firm, unyielding kind, de- 
pending at this advanced stage on the deposition of new bone, and cer- 
tain conditions connected with that process. 

Constitutional Symptoms. — Violent inflammatory irritative fever at- 
tends the first stages of necrosis. If the constitution be good, and not 
reduced by long-continued and extensive suppuration, hectic fever may 
not come on ; but there is much reason to apprehend it, if the constitu- 
tion be feeble, or the disease very extensive, or the articulations 
affected. 



NECROSIS. 



309 



Fig. 92. 



Sequestrum. — The sequestrum, or dead portion of bone, is always of 
an ivory-white appearance, except when it is exposed to the atmosphere 
through the soft parts, or is situated at the bottom of a large ulcer : it 
is then of a dark brown, or even black colour, in consequence of the 
action of the air. In general necrosis, that is, when the whole thickness 
of the shaft perishes, the sequestrum is situated within the newly-depo- 
sited bone ; in other words, the new bone surrounds or embraces the 
sequestrum, which is observed to be somewhat reduced in size, in com- 
parison with the original bone. Some authorities suppose, that the 
absorbents have the power of removing a portion of the sequestrum, 
into the system. Mr. John Hunter, Sir W. Blizzard, and Professor 
Russell of Edinburgh, held this opinion ; as do also Mr. Lawrence of 
London, and M. Velpeau of Paris. 

Messrs. Gulliver, Stanley, and Liston, maintain, 
that the sequestrum cannot be acted on by the ab- 
sorbents. Mr. Liston observes, "But a dead portion 
of bone detached from the surrounding parts, is in 
every respect an extraneous body, and is not and can- 
not be, acted on by the absorbents any more than a 
piece of metal, wood, or stone. Some have gone so 
far as to affirm that portions of foreign bodies, liga- 
tures, &c, are absorbed, but this opinion is altogether 
too absurd to require any contradiction ; the knots of 
ligatures, like portions of glass or other foreign sub- 
stance, become surrounded with a dense cyst, and 
often remain in the body for a long time ; so do por- 
tions of dead bone, separated by the process here 
described. A series of experiments were made by 
Mr. Gulliver, in order to put this question at rest, 
many of which I witnessed and assisted at, and 
several also I repeated. Setons of bone were in- 
serted, and worn for a long time ; thin plates of 
bone were confined on suppurating surfaces, pieces 
of bone were inserted in the medullary canal of 
various animals, and kept there for months, and in 
one instance for more than a year. These foreign 
bodies were weighed with the greatest care and accu- 
racy before and after they were so exposed, and were 
found unaltered in any respect." That the seques- 
trum is often much less than the original bone, is a 
fact which is beyond all doubt ; but absorption does 
not, and cannot take place, except through the me- 
dium of the vessels of the sequestrum, before it has 
lost all its vitality. 

Separation. — Respecting the process by which the dead portion of 
bone is separated from the living, the older writers had very vague 
ideas. Hippocrates stated that separation was accomplished by fleshy 
Some supposed that it was effected by the pulsation, 



i 



granulations 



Fig. 92. Drawing of a preparation in my own collection. 



310 



NECROSIS. 



others by the distension of the vessels of the parts ; and Mr. Benjamin 
Bell thought that the dead bone was separated by suppuration and 
granulation. The investigations of Wiedmann have set this question 
at rest. "The parts surrounding the dead portion directly become pre- 
ternaturally vascular. A groove is next formed all round the seques- 
trum, which is generally believed to be produced by the action of the 
absorbents of the adjoining living bone, or, as Mr. Hunter first demon- 
strated, the groove is formed by the absorption of that part of the 
living bone which is contiguous to the dead ; its earthy matter being 
first taken away, and then its animal part, the groove begins on the 
surface, and extends gradually more and more deeply, until the dead 
portion is completely undermined and detached." 

Reproduction. — The power of reproduction varies much in the diffe- 
rent bones of the body, being great in some, and less in others, while 
there are those in which it is not at all manifested. It is, of course, 
much greater in young healthy subjects, than in old 
Fig. 93. debilitated persons. Though the long bones, the 

lower jaw, the clavicle, and the scapula possess the 
power of reproduction, to a very considerable extent, 
the short cuboid bones cannot be reproduced. A 
case is related by Wiedmann, in which nature effected 
reproduction of nearly the whole of the lower jaw ; 
and one by Chopart, in which the clavicle was re- 
produced. An instance is also on record, of the 
reproduction of nearly the whole of the scapula. 
Portions of the cranium under particular circum- 
stances may, to a certain extent, be reproduced ; but 
if both the tables of the cranium be destroyed, to- 
gether with the pericranium, there will be very slight 
reproduction ; for the dura mater has very little 
tendency to form new bone. This is the reason why, 
after the operation of trephining, the pericranium 
and both tables of the skull being removed, reproduc- 
tion does not take place to any great extent. 

From what source is the New Bone derived ? — 
This is indeed a " questio vexata." Different patho- 
logists give different answers to the following ques- 
tions, Whether Nature, for the accomplishment of her 
purpose, employs the vessels of the periosteum — or 
those of the medullary membrane — or those of the old 
bone itself? It seems clear that in external necrosis, new granulations 
spring up from the living bone, and reproduction is effected in the same 
manner as in simple ulcer of bone. In internal necrosis, it is supposed 
that the living cortex or outer lamella of the bone, which becomes pre- 
ternaturally vascular, swollen, and softened, is the source of the new 
bone. That it cannot be by the vessels of the medullary membrane, is 
manifest from observation ; for in this form of necrosis the medullary 
membrane is completely destroyed. In general necrosis, or those cases 



Fig. 93. Entire regeneration of Tibia. Drawn from a preparation in my own collection. 



NECROSIS. 311 

in which the entire thickness of a bone, and the medullary membrane 
perish, it is believed that the new bone is derived from the periosteum 
of the old bone. Duhamel first mooted this opinion, which Troja after- 
wards supported. Troja produced necrosis by passing a red-hot iron 
into the medullary canal of various animals, and he ascertained that, 
when a portion of bone is about to perish, the periosteum becomes 
detached and raised up from the bone, and the space is occupied by 
purulent matter. Dr. Macartney had an opportunity of witnessing 
this separation of the periosteum from the bone in the human body, 
in consequence of destruction of a small portion of the medullary mem- 
brane by disease. The periosteum becomes very vascular, and thereby 
is rendered soft, pulpy, villous, and perfectly red on the surface in 
contact with the bone, the cellular tissue external to it also becoming 
swollen. The central part of the periosteum is next converted into 
cartilage, and afterwards into bone, so that the new bone is formed in 
the centre of the periosteum. "Some pathologists deny the ossific 
power of the periosteum, and claim the whole production of new osseous 
substance for the bone itself. That the process of 'reproduction maybe 
accomplished in this way, I am not prepared to deny, but that it is not 
necessarily or always so performed, will I think appear from the following 
case : — "A girl, twelve years of age, strained her ankle, in the month 
of March, 1835. Inflammation followed, extending up to the knee, and 
attended with violent fever. She was brought to the hospital, and 
placed under my care. Incisions were soon afterwards made to evacuate 
a large collection of matter, which had formed in the leg ; and the bone 
being found dead, while the patient's strength w T as rapidly going away, 
I amputated the limb above the knee, five weeks after the injury had 
been received. The girl recovered and is now well. In examining the 
limb to ascertain the extent to which the bone had died, I found that it 
was partially surrounded by the commencement of a new one. The 
shell had already acquired considerable firmness at some parts, but was 
not equally thick throughout, and did not seem fixed to the ends of the 
old shaft. This observation led to a very careful dissection of the parts 
concerned : and they are now before the Society. It will be seen that the 
tibia had died very nearly from end to end, and that the new shell 
enclosing it had been formed in the periosteum. The new osseous 
substance may be observed at some parts, in the form of distinct scales. 
At other parts it looked as if it had originally consisted of separate 
portions, and been composed by their union. The periosteum connecting 
these portions to each other, and to the extremities of the bone, was not 
thickened beyond its natural condition, and where it covered the posterior 
surface of the tibia, though quite detached from the old bone, had not 
suffered any further change. There is here then an instance of a bone 
dying suddenly in consequence of acute inflammation, without any 
thickening being previously found in its neighbourhood, and nevertheless 
succeeded by the production of a new osseous shell, which evidently 
could not proceed from the old bone, and no less evidently depended on 
an ossific process resident in the periosteum. As Nature is not capri- 
cious or variable in her proceedings, I regard this case as sufficient of 
itself, without any further evidence, to establish the ossific power of the 



312 NECROSIS. 

periosteum. But with the view of making the matter still more clear, 
I performed the following experiments. I exposed the radius of a dog, 
and removed an inch and three-quarters of it, together with the perios- 
teum. At the same time I exposed the radius of the other leg, and 
removed a corresponding portion without the periosteum, which was 
carefully detached from it, and left quite entire, except where slit open 
in front. Six weeks afterwards the dog was killed, and the bones 
examined. In the one from which a portion had been taken, together 
with the periosteum, the extremities were found extended towards each 
other in a conical form, with a great deficiency of bone between them, 
and in its place merely a small band of tough ligamentous texture. In 
the other, where the periosteum had been allowed to remain, there was 
a compact mass of bone not only occupying the space left by the portion 
removed, but rather exceeding it in thickness. This experiment, when 
repeated, aiforded the same results. 

" I next exposed the radius of another dog, and separated the perios- 
teum from the bone, as in the former experiment ; but then instead of 
cutting out the denuded bone, inserted a thin plate of metal between it 
and the periosteum. The edges of the membrane, and then those of the 
skin were sewed together, and the wound healed kindly. At the end of 
six weeks, I dissected the limb, and found a deposition of osseous sub- 
stance in the periosteum, forming a bony plate exterior to the metal, 
and not connected to the old bone, except by the membrane. I lastly 
exposed the radius of a dog, and cut away the periosteum to the same 
extent that it had been detached in the experiment just mentioned, and 
surrounded the denuded bone with a piece of metal. At the end of six 
weeks I found a thick tough capsule formed, enclosing the metallic 
plate, but having no osseous substance in it. The evidence which has 
now been adduced seems to me sufficient for putting beyond all question 
the power of the periosteum to form new bone, independently of any 
assistance from the old one." — Syme's "Principles of Surgery," pp. 
191-3. 

From the case and experiments published by Professor Syme, it seems 
warrantable to conclude, that the new bone is formed within the centre 
of the old periosteum, which first undergoes the various preparatory 
changes already described. The observations of many other authorities 
have led them to the same conclusion ; and I have for years exhibited 
to the Class of Surgery in Marischal College, a beautiful preparation, 
still in my possession, which most clearly demonstrates the vascularity 
of the inner surface of the periosteum, the deposition of ossific matter 
within its centre, and the perfect continuity of the altered portion, in 
which is contained the new bone, with the periosteum of the neighbour- 
ing portions of bone which are not involved in the disease. 

Such seems to be the correct doctrine regarding the source of new 
bone in general necrosis ; but there are some who embrace this opinion 
only in part. They agree that the new bone is derived from the perios- 
teum as its source, but consider that it is not developed in the centre, 
but formed on its inner surface ; and affirm that a secretion of lymph 
takes place between the inner surface of the periosteum and the bone, 
•'which undergoes the preparatory change into a gelatinous or cartila- 



NECROSIS. 313 

ginous tissue previous to its ossification." If this opinion be correct, it 
is difficult to explain the vascularity of the interior of the new bone. 

Dr. Macartney believes that the new bone is formed from the perios- 
teum, but seems to think that it is not developed in its centre, as the 
experiments and case of Professor Syme, and the preparation in my 
own museum tend to prove, but formed on its inner surface ; and he de- 
scribes the original periosteum as disappearing, not as becoming after- 
wards attached to the new bone. He remarks that u the first and most 
important circumstance is the change which takes place in the organi- 
zation of the periosteum ; this membrane acquires the highest degree of 
vascularity, becomes considerably thickened, soft, spongy, and loosely 
adherent to the bone. The cellular substance also, which is immediately 
connected with the periosteum, suffers a similar alteration ; it puts on 
the appearance of being inflamed, its vessels enlarged, lymph is shed 
into its interstices, and it becomes consolidated with the periosteum. 
These changes are preparatory to the absorption of the old bone, and 
the secretion of the new osseous matter, and even previous to the death 
of the bone which is to be removed. In one instance I found the perios- 
teum vascular and pulpy, when the only affection was a small abscess 
of the medulla, the bone still retaining its connexion with the neighbour- 
ing parts, as it readily received injection. The newly organized perios- 
teum, &c, separates entirely from the bone, after which it begins to 
remove the latter by absorption ; and while this is going on, its inner 
surface becomes covered with little eminences resembling granulations. 
In proportion as the old bone is removed, new osseous matter is dis- 
persed in the substance of the granulations, while they continue to grow 
on the old bone, until the whole or a part of it is completely absorbed, 
according to the circumstances of the case. What remains of the in- 
vestment after the absorption of the old bone and the formation of the 
osseous tube which is to replace it, degenerates, loses its vascularity, 
and appears like a lacerated membrane. I have never had an opportu- 
nity of examining a limb, a sufficient time after the termination of the 
disease, to ascertain whether the investment be at last totally absorbed ; 
but in some instances I have seen very little remaining. During the 
progress of the disease the thickened cellular substance which surrounded 
the original periosteum, becomes gradually thinner, its vessels diminish, 
and it adheres strictly to the new-formed bone, to which it ultimately 
serves as a periosteum." I have introduced the above extract because 
it well describes some points, and gives a distinct account of the writer's 
views ; but from what has been previously stated, it will be seen that I 
follow the authorities whose views do not altogether coincide with these. 
Mr. Stanley is of opinion that when necrosis is attended with destruc- 
tion of the bone and of the medullary membrane, the bone may be re- 
generated from three sources, namely, from the periosteum which in- 
vested the old bone, or from the articular ends of the old bone; or, if 
the periosteum be destroyed, from the soft parts which surrounded it. 
He states that he destroyed the medullary membrane in a dog's tibia, 
and removed the periosteum, and yet reproduction ensued from the 
vessels of the surrounding cellular tissue, which became exceedingly 
condensed, so as to form a periosteum. The results of some of the ex- 



314 



NECROSIS. 



i 



periments of Dupuytren, Breschet, and ViHei-mC, on the formation of 
callus, in some respects agree with the evidence furnished by the ex- 
periment of Mr. Stanley. 

Cloacce. — In the sides of the newly-formed bone are 
Fi g- 94 - observed a number of foramina, called by Wiedmann, 

Cloacce, and by Troja, foramina grandia, which serve 
as an outlet for the extraction of the sequestrum, pro- 
vided it be not too large, and for the escape of the 
purulent matter confined within the cavity of the bone. 
The cloacae generally present themselves in the middle 
or under third of the bone, and are usually of an oval 
shape, and oblique in their direction. Mr. Davies, and 
some others suppose that the cloacae are formed by the 
^ii matter secreted in the interior of the new bone, which, 

from its great quantity distends, and ultimately bursts 
the periosteum, thereby giving rise to these apertures. 
According to Wiedmann, this doctrine is incorrect, for 
cloacae are observed in situations where matter does 
not exist. Others attribute their formation to the cor- 
rosive qualities of the pus; but it seems more probable 
that they are occasioned by the non-deposition of osseous 
matter, at certain parts in the centre of the periosteum. 
In some preparations, the parts where bone has not 
been deposited, are filled up by periosteum. In a pre- 
paration in my collection, there are several cloacae filled 
up by periosteum, which is evidently continuous with 
that which covers in, and that which lines the outer 
and inner surfaces of the neighbouring portions of new 
bone, these portions being clearly deposited in the 
centre of the periosteum. 

After the entire removal of the sequestrum, the new bone gradually 
becomes consolidated and smooth oh the surface, by the action of the 
absorbents, and is lined by a medullary membrane. 

Treatment, — Preventive treatment should be first employed with an 
activity commensurate with the severity of the symptoms, and the 
strength of the patient. If the ostitis proceed from syphilis or scrofula, 
in addition to other remedies, the preparations of iodine, especially the 
iodide of potassium, with sarsaparilla, will be found valuable. As soon 
as the existence of purulent matter is detected, free direct incision 
should be made ; which will save much time, alleviate suffering, spare 
the strength of the patient, and circumscribe the extent of the disease. 
If hectic fever supervene, the strength of the patient must be supported 
by means of tonics, pure air, and suitable diet and regimen, until the 
process of separation be completed. In fact, the duty of the surgeon 
during the process of separation, which is a work of nature, is to keep 
the limb in a quiescent state, and to combat all untoward symptoms as 
they may arise. 

The Process of Extrusion. — The efforts of nature in this process 
being feeble, the surgeon ought to interfere, and afford the necessary 



Fig. 94. Drawn from a preparation in my own collection. 



RICKETS. 315 

assistance^ for the removal of the necrosed part. The proper period for 
this interference is, when the sequestrum has been separated from the 
living portion ; but first, the surgeon should consider the course of the 
cloacae, .and endeavour to form some opinion of the size of the seques- 
trum ; then he should make a free direct incision, generally longitudinal 
in its direction, not too long, as there is danger of hemorrhage, nor too 
short, as the difficulty of extraction would be thereby increased, and the 
operation rendered unnecessarily tedious. When the sequestrum is 
loose, it may easily be removed by a pair of forceps, if the cloacae be 
sufficiently large. Sometimes it is necessary to cut a portion of the 
new bone which confines the sequestrum, or to divide the sequestrum 
itself by Liston's forceps, or Hey's saw, or some other convenient in- 
strument. " The instruments," Mr. Liston observes, "and especially 
those for extraction, ought to be very powerful and suited to the pur- 
pose ; for in the employment of inefficient means there is much folly 
and cruelty." After the operation, which is generally attended with a 
profuse hemorrhage, the wound should be filled with lint, and the limb 
placed in an elevated position. Antiphlogistic means may be necessary 
to prevent ostitis. 

There are certain unfavourable cases of necrosis in which amputation 
is not only warrantable, but indispensable. If the hectic fever, caused 
by the long-continued suppuration, threaten to prove fatal ; or if the 
neighbouring articulations become involved in the disease, amputation 
is the only possible means of saving the patient's life. The bones of 
the tarsus and carpus, as was previously stated, are never reproduced ; 
and sometimes, in very weak, debilitated persons, there is no reproduc- 
tion in the long cylindrical bones. In these cases, also, amputation is 
admissible. " The treatment," Mr. Liston says, "may be summed up 
in a very few words. Prevent the necrosis, if possible, open abscesses 
whenever they appear, encourage the patient to move the neighbouring 
joints, support the strength, remove sequestra when loose, but do not 
interfere until they are ascertained to be so, give the limb proper sup- 
port, and rest when a large sequestrum is formed. When fracture has 
taken place, when the health has been undermined, or when neighbour- 
ing joints have become diseased, amputate in order to save the life, if it 
be impossible to save the limb." 

RICKETS. 

The spine was by the Greeks called paws, from which is formed ra- 
chitis, strictly meaning, disease of the spine ; and from rachitis is de- 
rived the English word rickets. The terms rachitis, and rickets, are 
not, however, used to denote a disease of the spine, but one in which 
there is a* preternatural softness of the osseous system, affecting the 
spine in common with other parts ; and these names were originally 
applied to the disease from an erroneous impression which at one time 
prevailed, that it originated in the vertebral column. It is a remarkable 
fact, that this disease appears to have almost escaped observation until 
the middle of the seventeenth century, there being no distinct account 
of it given by the ancients, nor by any author of the middle ages. It 
was first described by David Whisler, in a tract published in 1645, en- 



316 RICKETS. 

titled, " De Morbo Puerili Anglorum dicto The Rickets ;" but it was 
more fully described in 1671, by Glisson, in his treatise, " De Rachitide, 
Sive Morbo Puerili." The last-mentioned author states, that it first 
appeared in England in the middle of the seventeenth century, since 
which time it has been a well-known disease in these islands, and in 
many other parts of Europe. It can scarcely, however, be supposed 
that the disease did not exist previous to the above period, but merely 
that it escaped particular observation. Dr. Craigie remarks, " Its oc- 
currence in infancy only was the cause of its escaping observation ; its 
influence, however, in leaving more or less deformity of the skeleton, 
must have at all times attracted notice. Deformed dwarfs have been 
known in all ages ; the gibbi, the vari, and the valgi of the Romans 
must have been more or less rachitic in their infancy. From this cause 
the deformity of Thersites might have originated. It is also to be 
remarked, that Fabricius Hildanus delineates the serpentine lateral 
curvature of the spine in a girl of eight, whose bones were soft as wax, 
which could be produced by no other cause save rickety softness." 

Symptoms. — This disease generally attacks children between six 
months and three years of age ; but it is often known to occur at an 
earlier period, and a few instances are recorded of its taking place in 
the foetus. Pinel describes the skeleton of a rickety foetus. University 
College Museum contains a splendid specimen which I have examined ; 
and Soemmering, Bordenan, Loder, and others testify to the fact that 
the disease is sometimes met with affecting the bones of the foetus. 
From a state of apparent vigour the child begins gradually to decline in 
health, and to lose his liveliness ; the muscles diminish in size and be- 
come loose and flabby, causing that diminished appearance of the extre- 
mities and neck, which contrasts strangely with enlargements perceptible 
in other parts of the body. In the progress of the disease there is much 
general weakness ; the skin loses its elasticity and becomes pale, and, 
in aggravated cases, of a dusky appearance ; the digestion is often im- 
paired ; the breath has a sour smell, and the abdomen becomes enlarged, 
and has to the touch a doughy feeling : this enlargement, for the most 
part, arises from distension of the intestines with gas. It has some- 
times been believed to be produced by disease of the spleen, or of the 
liver, and more especially of the mesenteric glands. There can be no 
doubt that in patients affected with rickets, these organs are often found 
diseased ; nor is this at all surprising ; but that such disease forms no 
essential part of the state of the body in rickets, is evident from the 
fact that, in many instances, there is found no diseased condition of any 
internal parts except the bones. There is softness of the bones from 
the interruption of the ossific process ; and becoming, in consequence 
of this softness, flexible and incapable of offering resistance, they yield 
to the superincumbent weight and to the action of the muscles ; and 
hence result various unnatural conditions observable in the extremities, 
the spine, the chest, the pelvis, and the head. 

The upper and lower extremities frequently exhibit a remarkable con- 
trast of appearance ; the former, from not having to support any weight, 
are in general proportionate and free from curvature, while the latter 
are bent so as to become much shorter than natural. The bones give 



RICKETS. 



317 



way principally from the effect of the superincumbent weight, and partly 
also from the effect of the muscles. The form which they assume in 
the limbs is generally an exaggeration of the natural configuration ; by 
which I mean, an unnatural degree of the curvature proper to the bones. 
The lower limbs exhibit great varieties of deformity ; they are often 
bent laterally by the action of the muscles, and in such cases they are 
always bent to the side on which the muscles act most powerfully. The 
femur may be bent forwards, or laterally, or forwards and outwards ; 
the tibia may exhibit a curvature forwards ; or the knees may both fall 
inwards with the feet thrown outwards ; or both the extremities may be 
together thrown to one side, forming a curvature of the whole length of 
the extremities with the greatest convexity at the knees, and directed 
to one side and the concavity to the other. Although, as it has been 
already stated, the bones of the upper extremities are more rarely 



Fig. 95. 



Fig. 96. 



Fig. 97 





affected than those of the lower, yet they do sometimes suffer to a cer- 
tain degree both as to length and size. The clavicle may be bent un- 
naturally forwards, partly by the weight of the shoulder, and partly by 
the action of muscles going from the front of the chest to the bones of 
the extremity ; and the humerus, radius, and ulna may also become bent 
in directions determined by the actions of the muscles. The spine ex- 
hibits in a marked degree the effects of rickets, the weight of the head, 
and other superincumbent parts, bending it in various directions ; and 
with distortion of the spine is usually associated deformity of the chest, 
which is sometimes flattened laterally by the ribs falling in on both sides, 
in which state the sternum is pushed forwards, and the front of the chest 



Figs. 95-97. From preparations in my own museum. 



318 



RICKETS. 



acquires somewhat of the form of that cavity in a bird, and hence the 
expression " chicken breasted" has been used to describe that peculiarity 
of form. The chest, in these cases, may be flattened on one side, and 
rendered very convex on the other, as in lateral curvatures of the spine 
from other causes. The chest is shortened on the flattened side, and 
the intercostal spaces very much diminished from above downwards ; 

Fig. 98. Fig. 99. 



7 




whereas, on the convex side, the chest is lengthened, and the intercostal 
spaces are larger than natural. This condition of the chest often occa- 
sions a compression of the thoracic viscera, and thus interferes with the 
easy performance of their functions ; hence arise the difficult breathing 
and palpitations which are frequently observable in such cases. With 
respect to the pelvis it was the opinion of the late Mr. John Shaw, that 
it will be found distorted only in those cases where marks of rickets are 
found in other parts of the skeleton besides the spine and chest. He 
made an examination of an extensive series of skeletons in which there 
were curvatures of the spine, and he found that in some, the deformities 
were confined to the spine and chest, while in others, he observed marks 
of rickets in other bones also ; but in no single instance of the former 
class did he find any distortion of the pelvis ; and he therefore concluded 
that in cases of rickets, although the spine and ribs may be deformed, 
the pelvis will not be found distorted, unless the disease affect the skele- 
ton generally. The distortions of the pelvis are various ; the bones may 
be pressed to one side, or the inlet may be diminished from before 
backwards, or if the softening be very great, and the patient be able to 
walk, the ossa innominata may, to a certain extent, be approximated 
towards each other at certain parts by the pressure of the thigh-bones 
against the acetabula. The head is larger than natural, and has a sin- 
Figs. 98, 99. From preparations in my own collection. 



RICKETS. 319 

gular appearance from its two grand divisions becoming disproportioned 
to each other, the facial portion retaining its natural size, while the 
cranial is much enlarged. It is an observation made by some authori- 
ties that in rickety patients there has been found a more early develop- 
ment than usual of the mental faculties. 

State of the Parts. — In rickets, the earthy matter is deficient, and the 
bone is light, spongy, and soft, of the consistence of cartilage, and is 
easily cut with the knife. The vessels of the bone appear numerous 
and large, and are loaded with dark-coloured blood. The bone is of a 
red colour varying in shade from pink to brown. The walls of the 
long bones become very thin, while the bones of the cranium are con- 
siderably increased in thickness, but are changed in structure so as to 
become reticulated and spongy. The interior of the long bones presents, 
as during foetal life, a loose and reticulated arrangement, with some- 
what of the appearance of a homogeneous substance instead of a distinct 
medullary cavity and cancellated structure ; and instead of being filled 
with medulla or any oily secretion, as in the healthy state, it contains a 
reddish or brownish serum. The periosteum is said by Bichat to be 
generally thickened ; other observers have also found it thickened and 
detached ; but Mr. Stanley, who examined an extensive series of bones 
affected with rickets, did not find this thickened appearance. The con- 
dition of bone above described may be succeeded by one of growth and 
strength, in which the bones increase in density and size by a process 
resembling, with one exception, that by which the natural growth of the 
bones in a sound state is carried on. A medullary canal is formed ; in- 
stead of the reddish serum, the natural oily secretion is deposited ; and the 
distinction between cancellated structure and the compact shell becomes 
perceptible. The great peculiarity is, that the bones become thickest 
at the smaller curvatures, where the power of resistance is most required, 
and the deposition not only takes place on the outer surface, but in 
some specimens extends into the interior, so as to encroach on the medul- 
lary canal, which has been known in some instances to have been at 
certain parts even obliterated by it. 

Treatment. — The proper treatment consists in the employment of all 
judicious and available means for removing weakness of constitution, 
and strengthening the general system. For that purpose the most ap- 
propriate remedies are, residence in a dry and pure air; sleeping in a 
large, airy apartment ; free exposure to the light and to the sun's rays; 
nutritious and light diet, attention to clothing, and particularly in the 
cold season wearing enough to keep up free cutaneous circulation ; cold 
or sea-bathing at the proper season, if the patient be strong enough to 
undergo the exertion, and if that should not be found advisable, bathing 
in tepid salt water, or sponging the body ; and the regular employment 
of friction by means of the hair-glove, or flesh-brush. The state of the 
digestive system, and particularly the due regulation of the bowels 
should be attended to ; and, together with the above means, which are 
of the utmost importance for stregthening the general system, it is ad- 
visable to give some tonic medicine. Of the various remedies belonging 
to that class the preparations of iron seem to be usually employed with 
the greatest advantage. Exercise to an extent not inducing fatigue is 



320 MOLLITIES OSSIUM. 

beneficial ; but after exercise, and occasionally at different other periods 
during the day, the patient should recline to relieve the weak parts 
from the pressure of the superincumbent weight. 

MOLLITIES OSSIUM. 

The disease known by the names mollities ossium, osteomalacia, ma- 
lakosteon, and osteo-sarcosis, is extremely rare, and appears to have been 
unknown to the ancients. The first distinct account of this malady was 
given by Gabriel in 1688. He met with an instance of it in a lady, 
whose bones were flexible, and converted into a reddish substance des- 
titute of fibres. Cases were published in 1691 by Saviard, and in 1700, 
by Courtial and Lambert ; in the " Memoirs of the Royal Academy of 
Sciences" for 1752, Morand detailed the remarkable case of Madame 
Supiot, and since that time many well-marked examples are recorded 
by different observers. From there being so far a resemblance between 
rickets and mollities ossium, that in both there is softness of bone and 
deficiency of phosphate of lime, some have supposed them to be the same 
malady ; but they differ so completely from each other in many re 
spects, that it is very evident they ought to be regarded as entirely 
distinct diseases. Some of the striking points of difference are the 
following. Rickets is a very common affection ; mollities ossium is so 
extremely rare, that, in a period of more than thirty years, no example 
of it occurred in any of the London Hospitals. Rickets is by no means 
a dangerous disease ; mollities ossium has invariably proved fatal. 
Rickets is a disease of early life, and is equally common in both sexes ; 
whereas mollities ossium takes place in the middle of the period of life ; 
and all the well-marked examples of it that are recorded, so far as my 
reading extends, have been in females, with the single exception of the 
case of Jas. Stevenson, who was attacked with the disease when thirty- 
five years of age, and after languishing in bed six years died in 1785. In 
rickets the disease commences while ossification is imperfect, the phos- 
phate of lime never having been deposited to a sufficient extent ; molli- 
ties ossium takes place after the process of ossification is perfect, and 
the phosphate of lime, previously deposited, is in a great measure re- 
moved. . In mollities ossium the urine is loaded with a deposit consist- 
ing of phosphate of lime ; in rickets there is no such deposit. In mol- 
lities ossium the patient complains of pain in the bones, and is distressed 
with irritative fever ; whereas, these symptoms are not present in rickets, 
or if present, they arise from other constitutional diseases. By way of 
further description of this very remarkable disease, I shall state a few 
particulars of some of the most extraordinary examples on record. The 
first case 'I shall mention is that of Ann Elizabeth Queriot, recorded by 
Dr. Hosty in the forty-eighth volume of the " Philosophical Transac- 
tions." This person was attacked at the age of thirty-six, soon after the 
birth of her first child. She was distressed with fever, profuse perspira- 
tion, and violent pains in the bones ; and the disease was attended with 
a deposition of a white sediment in the urine. The disease continued 
about two years, and the bones became so soft that they bent in various 
directions, and so much distorted that her lower extremities turned up- 
wards so as to lie in a line parallel with her body. After her death the 



EXOSTOSIS. 321 

bones were found to be so soft, that they could be easily cut with a 
knife, and so flexible, that although the extremities had assumed a 
curved direction, they could easily be laid straight. The cavities of the 
bones contained a reddish blood-like fluid instead of marrow. No cause 
could be assigned for the disease, and during its progress she was three 
times pregnant. 

Another remarkable case is that of Madame Supiot. Her disease 
was attended with great general weakness, fever, pains over the whole 
body, and a white sediment in the urine. General softening took place 
in her bones, so that they yielded to the action of the muscles, and the 
distortion was so complete, that her lower extremities were drawn up- 
wards, and her feet lay by the sides of her head. Her disease lasted 
five years, during which period she was three times pregnant. For 
some time before she was attacked with this disease, and for two years 
afterwards, she was addicted to the habit of eating kitchen salt, and it is 
stated that she used to take a pound and a half a week without mingling 
it with her food. To this habit some have attributed her disease ; a 
habit, it may be remarked, to which some of the other persons who have 
been subjects of this malady were addicted. After death, her bones 
were found to be soft, sectile, and flexible, and loaded with a bloody 
fluid. 

As further peculiarities in the state of the bones in this disease, it 
may be stated, that the cancellated structure disappears, and in its 
place is found a reddish soft substance, from which on a section being 
made, a bloody serum exudes ; and the place of the marrow is occupied 
by a substance like clotted blood. 

FRAGILITAS OSSIUM. 

In this state the animal matter is comparatively less abundant than the 
earthy. It occurs in old age as a consequence of the change which 
takes place in the structure of the bones at that advanced period ; but 
it is also met with in middle age, in which case it is symptomatic of 
some other disease, such as cancer, scurvy, or syphilis : in these states it 
sometimes prevails to a great degree, and is rarely amenable to treat- 
ment. 

[EXOSTOSIS. 

Exostosis is an unnatural enlargement of bone, exhibiting various 
sizes and shapes. The tumour may involve the whole bone, or it may be 
confined to a small portion. It may form rounded prominences, which 
are attached by narrow or broad bases ; and sometimes the growth has 
the form of elongated spines terminating in a point. The increased 
development of bone may arise from the periosteum, the cellular struc- 
ture, or from the medullary membrane. 

The structure of the tumour resembles ordinary bone, and may be 
either laminated,' cellular, or compact, in its interior. All bones are 
liable to exostosis, but it more frequently occurs in long bones, particu- 
larly in the humerus, femur, and tibia. There may be some constitu- 
tional peculiarity favouring this bony deposit, but the predisposing 
causes are generally syphilis, scrofula, and gout. Violence frequently 

21 



322 



SPINA VENTOSA. 



Fig. 100. 



excites inflammation in the bone, by which the equilibrium between 
absorption and deposit is destroyed, and the excessive deposit takes 
place in the manner that bones are originally formed 
and repaired. 

Symptoms. — Generally there is but little pain, in a 
healthy constitution, unless the tumour presses on 
parts particularly sensitive, but if syphilis or scrofula be 
the cause of the disease, there may be a dull, deep-seated 
pain. Pain is also more likely to be present when 
the tumour is of rapid growth ; but when the growth 
is slow, there is but little inconvenience unless it in- 
terfere with some important organs. It may press on 
muscles and impede their action, or it may impede 
the motion of a joint ; when growing from the orbit it 
may occasion protrusion of the eyeball ; or, if from 
the internal table of the skull it may cause epilepsy. 

Care must be taken to distinguish those tumours 
which are dependent upon syphilitic or scrofulous 
taints from those which are idiopathic, the latter being 
inconvenient generally from their size and weight, 
whilst the former may ulcerate and be attended with 
constitutional disturbances. 

Treatment. — If syphilis or scrofula exist, the con- 
stitutional remedies employed in these diseases must be 
mainly relied on ; at the same time pain may be re- 
lieved by leeches and anodyne applications. True 
idiopathic exostosis is generally but little diminished 
by medical treatment, and if it occasions no inconve- 
nience it should be let alone, but if it mechanically interferes with the 
function of any part, it is to be removed. The operation will in a great 
measure depend upon the size and form of the tumour. If it be 
spiculated, it may be cut down upon, and removed by bone-pliers or a 
fine saw; but if it has a large base, it may be chiselled off piecemeal. 
If it be impossible to reach it with instruments, the periosteum should 
be scraped away, so as to deprive it of its nutrition, and it may exfoliate 
or be absorbed. The edges of the wound are to be brought together, 
and inflammation carefully guarded against. 

SPINA VENTOSA. 

Spina ventosa is swelling involving the whole circumference of a bone, 
and of a regular form. It consists of a bony crust, which forms the 
walls of a cavity divided into compartments, which contain either an 
ichorous fluid, or a reddish, jelly-like substance ; or a cheesy, lardaceous 
substance, and sometimes pieces of cartilage or of dead bone. 

It commences with deep-seated, dull pain, which often is the result of 
external violence. The swelling gradually increases, the skin becomes 
red, and the shell bursts, discharging its contents. Sometimes the walls 
are formed merely of expanded periosteum. After the contents are 
evacuated, the cavity fills with fungous excrescences, which protrude 
through the opening, and which are very sensitive and easily bleed. 




OSTEO-SARCOMA. 



323 



Fig. 101. 



The disease probably commences in an inflammation and ulceration 
of the medullary membrane, which constantly enlarges the tubular 
cavity of the bone, and fills it with foul matter, at the same time there 
is going on a deposit from the external periosteum, which becomes ex- 
panded. At first, it might be mistaken for exostosis ; but, in exostosis, 
the tumour is firm and incompressible, whereas, in spina ventosa, it is a 
mere osseous shell. 

It is a disease of slow progress, and very difficult to cure. On the 
fingers, or metacarpal bones, long-continued pressure may perhaps effect 
a cure. At the same time, the patient should take iodide of potassium 
in large doses. Should the tumour burst, and it is recommended by 
some to open it, the cavity should be cleansed and injected with stimu- 
lating washes. 

OSTEO-SARCOMA. 

Osteo-sarcoma is a tumour formed upon a bone, but consists not 
merely of bone, but also of flesh, fat, jelly, and cartilage. It is de- 
pendent upon some constitutional vice, either 
venereal, scrofulous, or gouty, often excited 
by an external injury. 

Boyer considers that it corresponds to the 
cancerous affection of the soft parts, and 
that, after its removal by amputation, it 
will return in other parts of the body. 

The tumour becomes large and nodu- 
lated, and some parts are firm, and others 
are soft and elastic. Upon dissection, the 
muscles and tendons will be found to be ex- 
panded, and of a pearly-white colour. The 
various coverings will be found much matted 
together and firmly adherent to the bone. 
Upon cutting into the bone, it will be found 
to contain cells filled with medullary or ge- 
latinous matter, intersected with bony spi- 
cule. 

Its growth is attended with severe and lan- 
cinating pain. The skin is stretched and 
then inflamed, finally ulceration occurs, 
which produces hectic and death. 

Treatment. The treatment in the early 
stage of the formation is similar to that for 
exostosis, but amputation will generally be 
found necessary. — Ed.] 




324 



CHAPTER IX. 

DISEASES OF JOINTS. 

ACUTE SYNOVITIS. 

Anatomical Characters.— The first effects of inflammation of a synovial 
membrane are, that the membrane, instead of being pale, thin, smooth, 
and translucent, as in the sound state, becomes red, preternaturally turgid 
and opaque, with dulness of its surface. The redness depends on in- 
creased vascularity, and may present the appearance of crimson or 
brownish spots, or it may be diffused over the membrane. There is at 
the same time a preternatural secretion of synovia, which is of a more 
aqueous character than in the healthy state, and of a less albuminous 
quality. As the inflammation advances, other changes take place both 
in the membrane and in the fluid. The membrane becomes considerably 
thickened by interstitial exudation ; it has some degree of pulpiness 
with redness, and entirely loses its translucency. The absence of the 
natural smooth glistening appearance is more decidedly observed on its 
internal surface, to which lymph is often found adherent, giving it a 
rough appearance ; and if the inflammation be of considerable standing, 
the lymph may be effused not only on its internal surface, so as to make 
that surface irregular, and into the substance of the tissue, giving rise to 
thickening, but also into the cellular tissue external to the membrane, 
and by which it is connected with the surrounding parts. The mem- 
brane at this stage is much distended with a fluid of a serous character, 
having albuminous or curdy flakes floating in it, and hence called sero- 
albuminous. This is the stage at which adhesion of opposite sides of 
the membrane may take place, but such an occurrence is comparatively 
rare, partly in consequence of the great distension from synovia, and 
partly from the tendency of the inflammation to increase. At a more 
advanced period the internal surface is more extensively covered by 
lymph, which becomes in a measure organized, and forms a secreting 
surface. There are great varieties as to the extent and thickness of the 
effused lymph, and also of the appearance of its free surface. In many 
instances it covers the whole of the synovial membrane, so that no part 
of it can be seen on laying open the joint ; in some it is comparatively 
thin, and in others it forms thick projecting masses. These varieties 
occasion also a great difference with regard to the surface of the cavity 
of the joint, which thus exhibits a greater or less degree of irregularity. 
The adventitious tissue, as it has been called, becomes organized, and 
secretes purulent matter into the joint, giving rise to great distension. 



ACUTE SYNOVITIS. 325 

At this stage the articulation may be regarded as forming an acute ab- 
scess ; and if the synovitis should run its course, the matter may sooner 
or later point, making its way to the surface by interstitial absorption 
and ulceration, and at length be discharged by ulcerated openings ; an 
event which, though it gives temporary relief, is soon followed by a de- 
cided aggravation, much more frequently than by a diminution of the 
inflammatory action. From the extension of the inflammation to the 
cellular tissue around the joint, lymph and serum are deposited in it, 
and, in consequence, a doughy and (edematous swelling becomes percep- 
tible between the skin and the distended cavity of the articulation. 
Destruction of a portion of the membrane and subjacent cartilage by 
ulceration, and of the bone by caries, are frequent results of acute as 
well as of chronic synovitis. 

The above are the principal results of acute synovitis in unfavourable 
cases, where the inflammation attains a high grade ; but sometimes the 
inflammation terminates at an early stage in resolution, and thus struc- 
tural derangement is prevented ; sometimes it goes on to the effusion 
of lymph, and produces adhesion, to a certain extent, of the opposite 
surfaces of the membrane to each other, admitting ultimately a limited 
motion of the joint, but such adhesions, as has been already stated, are 
rare ; and sometimes, when the inflammation has attained a higher grade 
and produced suppuration, and the matter has been discharged, although 
such cases generally produce, at length, a total disorganization of the 
joint, they may terminate in anchylosis. 

Symptoms. — This disease, very rare in the child, and less uncommon 
in youth, is most frequently met with in the adult. The knee, ankle, 
and elbow are more liable to it than the other articulations, but it is 
most common in the knee. The first symptom experienced by the 
patient is pain, which though slight perhaps at first, gradually increases, 
and soon becomes very severe. It may be more intense at a particular 
part, but it is usually felt over the whole of the articulation ; it is 
aggravated by motion, which is always injurious and often intolerable, 
and generally by cold, and by the extended position ; it is diminished 
by rest, by heat, and by slightly bending the joint, and thereby relax- 
ing the structures ; hence the patient has an inclination to maintain the 
parts in this attitude. Almost synchronous with the pain is swelling, 
which at first depends entirely on the distension of the membrane by 
synovia. It is as uniform as the ligaments and tendons surrounding 
the joint will permit, being prominent where the synovial membrane is 
•not confined by these structures. The swelling has very distinct fluc- 
tuation ; and if the joint be superficially situated, this peculiarity is very 
evident, and even the fact of its being caused by a very thin fluid is dis- 
cernible, and thus an impression is conveyed of the stage as well as of 
the nature of the disease. As the disease advances, the swelling is 
caused partly by serous and albuminous effusion into the cellular tissue 
external to the synovial membrane, but chiefly by distension from the 
fluid within, which ultimately changes so as to become purulent. The 
serous and albuminous effusions cause the swelling to feel somewhat 
cedematous and doughy ; and though the fluctuation be still perceptible, 
it is more difficult from the examination alone to form an accurate and 



326 ACUTE SYNOVITIS. 

decided opinion, in every instance, as to the nature of the fluid within 
the joint. 

Motion of the joint is not only difficult, but painful, and often attended 
with a grating sensation, which is supposed by some to be caused at an 
early period by the change in the character of the synovia, which, 
becoming more aqueous and consequently less lubricating than in a 
healthy state, is less calculated to diminish the effects of friction. 
Whether this supposition may or may not be in part correct, it seems 
more likely that even at first this symptom depends very much on the 
swollen state of the membrane ; and at a more advanced period the 
impression forced on a careful examiner is, that it arises from the irre- 
gularity on the surface of the lining membrane. The parts external 
to the synovial membrane being involved in a low degree of inflammation, 
the skin is preternaturally sensitive, red, tense, and hot. The pain is 
increased on pressure, and the patient maintains the joint in a slightly 
flexed position. In many instances, the muscles of the limb are affected 
at times, and especially during sleep, with spasmodic twitches, which 
aggravate the symptoms ; and the rigidity of the muscles, particularly 
of the flexors, which maintain the joint slightly flexed, is preternaturally 
increased, and their bellies and tendons may in consequence be felt 
unusually tense under the common integument. 

The severity of the constitutional symptoms varies considerably 
according to the violence and extent of the inflammation, the grade in 
which it exists, and the peculiar constitution of the patient. At first 
the usual symptoms of inflammatory fever appear more or less distinctly 
marked, but they become more severe, as the disease advances to a 
higher grade. When the inflammation reaches the suppurating stage, 
there are frequently rigors, together with a marked aggravation of the 
symptoms. If the matter be discharged, there is often a diminution of 
the symptoms, but this is usually of very short duration ; and sooner 
or later the symptoms of inflammatory are changed into those of hectic 
fever, under which the patient will sink, unless the disease be arrested, 
or the joint removed. 

Causes. — The predisposing cause, which also, to a certain extent, 
modify the character of the attack, are rheumatism, scrofula, syphilis, 
and the use of mercury ; and so powerfully do these conditions operate, 
that where they exist, a very slight exciting cause, such as a bruise, a 
sprain, exposure to cold, a wound, or any injury near a joint is sufficient 
to induce the disease ; and, indeed, it occasionally comes on without any 
known exciting cause. The most frequent exciting cause, however, is 
cold, combined with damp, which is more apt to affect the more exposed 
articulations, as the knee, ankle, and elbow. Synovitis frequently takes 
place in the progress of diffuse suppurative phlebitis, and it is well known 
that in persons of rheumatic constitution, inflammation of the synovial 
membrane of various joints is occasionally produced by the excitement 
caused by gonorrhoea. 

Treatment. — This is both general and local ; the former consists of 
the early and decided employment of the antiphlogistic regimen and 
treatment in all their details. Bloodletting, when the general system 
is affected with inflammatory fever, should be employed to an extent 



ACUTE SYNOVITIS. 327 

proportioned to the age and strength of the patient, and the violence 
of the disease. The bowels should occasionally be smartly purged ; but 
the frequent employment of cathartic medicines is not advisable, as it 
would interfere with a most important indication, namely, to keep the 
affected joint at perfect rest. When the disease is not speedily arrested, 
it is of the utmost importance for checking the diseased action, and 
thereby preventing structural derangement, and for preserving the joint 
in a fit state for the future performance of its functions, to bring the 
system under the influence of mercury. With this view calomel and 
opium are prescribed with advantage. When circumstances render it 
injudicious to have recourse to mercury, much benefit is often experi- 
enced from the use of the tartrate of antimony, and in persons of a 
rheumatic diathesis the exhibition of colchicum, to an extent sufficient 
to produce in some degree its peculiar effects on the system, usually 
leads to the happiest results. Such are the principal remedies, as far as 
regards constitutional treatment in acute synovitis, and they ought to 
be employed at an early period, and to be carried to as great an extent 
as may seem necessary and judicious, so as to prevent, if possible, the 
occurrence of structural derangement. 

As regards local treatment, one of the most important indications is 
to keep the joint at perfect rest. The state of complete repose must 
be strictly enjoined not only during the acute stage, when in conse- 
quence of the pain caused by motion the patient has little inclination to 
move it, but also till all inflammatory action has subsided ; for when 
the inflammation has become chronic the symptoms are invariably aggra- 
vated after motion, although pain may not be felt at the time ; and it 
cannot be doubted that extensive disorganization has often resulted, and 
many a limb has been lost, from prematurely and imprudently resuming 
motion. The attitude in which a joint should be kept at rest, must vary 
according to the situation of the joint ; but it may be given as a general 
rule, that it should be maintained as nearly as possible in that position 
in which it will be most serviceable and convenient, provided the joint 
remains stiff, or with great limitation of its motion. The means to be 
employed for preserving the joint at rest may vary. The limb is often 
gently bound in the acute stage to a pillow, and at a later period to a 
suitable splint. Local depletion is important, either by leeches or cup- 
ping, or, which is often found to answer very well, first by the former, 
and afterwards by the latter. The efficient application either of cold 
by means of evaporating lotions, or of heat with moisture by poultices 
or fomentations will be found useful : in making the choice between 
these two applications, heat and cold, the best guide will be the patient's 
feelings ; for whichever is most grateful to the feelings will be most 
beneficial. By the judicious and early employment of the above consti- 
tutional and local treatment the inflammatory action is in many instances 
subdued ; and with the continuance of the antiphlogistic regimen and 
rest of the joint,* its effects disappear ; and then by gradual and cautious 
trials the functions of the articulation may be resumed. If, however, 
the inflammation does not yield under the above treatment, though 
carried to as great an extent as prudence will allow, it is advisable to 
employ some of the forms of counter-irritation, of which one of the most 



328 CHRONIC SYNOVITIS. 

efficient is by blisters. But it is important that care be taken never to 
apply a blister over a joint in acute synovitis, unless the joint be deeply 
seated, or the inflammation has become chronic, and depletion has 
preceded the application. The inflammation would probably be increased 
by a blister applied over a joint superficially situated, the disease in the 
acute stage being so susceptible of aggravation and there not being room 
as when the joint is deeply seated, for the blister to act on the principle 
of derivation. If it is ascertained beyond all doubt that suppuration has 
taken place, it is- advisable to discharge the matter as in other acute 
abscesses by free direct incision ; but as nothing could be more injudi- 
cious than to make an opening into a joint distended with serous or even 
sero-purulent effusion, the evidence of suppuration should be very clear. 
If any doubt remain, the nature of the fluid may be ascertained by the 
introduction of a grooved needle. After such an opening and the 
discharge of the matter, an attempt should be made to obtain anchylosis, 
and for this end rest of the joint and attention to all means likely to 
improve the general health are essential; but as might be anticipated, 
our hopes are often disappointed, and too generally it becomes needful 
to remove the limb in order to preserve the patient from sinking under 
the accompanying hectic fever. 

CHRONIC SYNOVITIS. 

Chronic synovitis most frequently occurs in persons who have been 
affected with syphilis or mercury, or who are of a rheumatic diathesis : 
it is, however, occasionally met with in others also. It is frequently 
excited by that kind of injury termed a sprain, or by any local mecha- 
nical injury, as a blow or a contusion, or by exposure to cold and damp. 
In many instances it is the form of perverted action ultimately assumed 
in cases which were originally acute. 

Anatomical Characters. — The synovial membrane becomes opaque, 
thick, and pulpy, and preternaturally vascular ; and its free surface, 
instead of being smooth, becomes villous, or granular, and the cavity of 
the joint is filled with a fluid which at first is serous, but ultimately by 
mingling with a puriform secretion, becomes sero-purulent ; or, from 
the absorption of the thinner part, entirely purulent. For a conside- 
rable period the changes are confined to the membrane and its contents, 
and hence arises the difference in the superimposed parts during the 
early stages of acute and chronic synovitis ; but by a continuation of 
the morbid action, or by the intervention of an acute attack, the extra- 
capsular filamentous tissue becomes affected, and infiltrated with a jelly- 
like substance, and the membrane may ulcerate and the cartilage be 
destroyed by ulceration ; and this may be followed by destruction of a 
portion of the bone and the total disorganization of the joint. 

Symptoms. — If the disease be chronic from the commencement, the 
early symptoms will differ from those of acute synovitis. There will be 
no redness of the skin, no particular heat, nor will the pain be very 
acute, nor much aggravated at the time by motion. On this account, 
patients have not the same dread of moving the joint as in acute inflam- 
mation ; but it is no less necessary to preserve it at complete rest, as 
motion is followed by an increase of the symptoms. The pain is not 



CHRONIC SYNOVITIS. 329 

only less severe, but is felt more at a particular part than over all the 
articulation. Swelling takes place in the course of a short time, but 
not so soon as in the acute form ; it is not uniform, but bulges out, 
principally in parts where the synovial membrane is not confined by 
ligaments or tendons ; and as the superimposed tissues are not in the 
first instance involved, fluctuation is exceedingly distinct. In some in- 
stances, from the thickening of the membrane itself, and the depositions 
into the superimposed tissue, which take place during the progress of 
the disease, the swelling has to a certain extent a doughy or elastic 
character, and the fluctuation becomes more obscure; but still, on care- 
ful examination, it can always be discerned. The motion of the joint is 
followed by pain ; the inclination of the patient is to preserve it more 
or less flexed, and the flexor muscles are found to be tense, the others 
flabby and relaxed. If the disease be of long continuance, the swelling 
of the joint becomes very great ; and presents a striking contrast to 
the rest of the limb, which is often greatly emaciated from interstitial 
absorption of all the structures, both hard and soft. Frequently the 
veins over the joints are greatly distended, and the skin from its wrinkles 
being unfolded by the tension, has a shining appearance. If the dis- 
ease run its course, the matter may point at a particular part, and 
make its way to the surface by interstitial absorption and ulcera- 
tion. 

In some instances the disease is chronic from the very commence- 
ment, in others it is at first acute and afterward chronic. In some 
cases the symptoms continue chronic throughout, and in others they 
are for the most part chronic, but with occasional aggravation from 
accession of acute symptoms. If the symptoms have been chronic from 
the commencement, the patient may not have experienced any inflam- 
matory fever ; whereas, if the disease was at first acute, the signs of 
inflammatory fever are exhibited while the acute stage continues. The 
constitutional disturbance, however, which sooner or later takes place 
in every instance where the disease does not come to a favourable ter- 
mination, is the accession of hectic fever, which will prove fatal unless 
the joint be removed. 

Treatment. — As regards the constitutional treatment, which is of 
very great importance, it may be said that in the absence of any pecu- 
liar cachexy, the chief points are to enjoin the antiphlogistic regimen, to 
regulate the bowels, to preserve the digestive apparatus, if possible, in 
a proper state for the performance of its functions, and to adopt all 
prudent measures for maintaining the general health. When hectic 
fever supervenes, the strength should be kept up as much as possible 
by nourishing diet, and such tonic remedies and other means, as seem 
most suitable to the particular circumstances of the case. When the 
disease arises from syphilis, a well-regulated course of mercury is 
necessary ; when from rheumatism, the Vinum Colchici will prove 
highly beneficial ; and when from the abuse of mercury, or from injudi- 
cious exposure during or after a mercurial course, the happiest effects 
often result from the use of sarsaparilla, combined with the iodide of 
potassium. In cases especially where synovitis is combined with in- 



330 CHRONIC SYNOVITIS. 

flammation of the periosteum, the last-mentioned remedies are often 
highly beneficial. 

With regard to local treatment, in this as in all cases where joints are 
diseased, it is most essential that rest be observed; if this be neglected, 
all other means will be of no avail. Local depletion by leeching or 
cupping, the latter being generally preferable in chronic synovitis, will 
be found advantageous in the early stage, not only for checking the in- 
flammation, but also for rendering it safe to employ counter-irritation. 
At the same early period the efficient application of cold is usually 
grateful to the feelings of the patient, and beneficial. But one of the 
most valuable remedies, both for subduing the inflammation, and also 
for promoting the removal of its effects, is counter-irritation, which will 
be most efficiently employed by the repeated application of blisters in 
the immediate neighbourhood rather than directly over a joint, unless 
it be deep-seated. 

These are the principal remedies on which reliance can be placed for 
checking chronic synovitis. The treatment, therefore, may be said, in 
the first instance, to consist in the employment of rest, local depletion, 
cold applications, and counter irritation by means of blisters. At a 
much later period, when the inflammation is considerably subdued, bene- 
fit is often derived from some of the other forms of counter-irritation. 
Some of the principal applications for this purpose are, small caustic 
issues, or the application of the moxa, in the proximity of the joint. 
Other excellent modes of employing counter- irritation are painting the 
joint with the tincture of iodine, or brushing it over with a strong solu- 
tion of the nitrate of silver, or, after having damped the skin with water, 
rubbing it very gently with the solid nitrate. These applications must 
be used with caution, and the surgeon must watch against recurrence of 
acute inflammatory action ; and to diminish that risk, it is prudent to 
delay the employment of some of the forms of counter-irritation until 
the acute inflammation has been in great measure subdued. 

Under the above treatment the inflammation and its effects may dis- 
appear, and in the course of time, by passive motion and friction, the 
motion of the joint may be restored, and the patient allowed to use the 
limb. Often, however, there remains a stiffness of the joint from the 
thickening of the soft tissues, sometimes hydrops articuli ; for the re- 
moval of which the following treatment is recommended : — 

Stiffness from Thickening of the Soft Tissues. — The principal remedies 
are, the repeated application of blisters, so often beneficial from their 
well-known effect in promoting absorption ; pressure by means of a roller 
with or without some discutient ointment ; friction by the hand with 
some dry powder ; warm water poured on the joint, which is useful not 
only from the relaxing effect of the heat combined with moisture, but 
also by causing friction, especially if it be poured from a considerable 
height; the vapour bath, together with shampooing in the bath, and 
passive motion. Whenever rubbing, shampooing, or friction is employed, 
the effects must be carefully watched ; and if the treatment should be 
observed to excite any inflammation, it must be immediately discon- 
tinued. Of course nothing could be more injudicious than to have re- 



SCROFULOUS CHRONIC SYNOVITIS. 331 

course to rubbing, friction, pressure, or motion, while any inflammatory 
action remains. 

Hydrops articuli is the name given to that condition in which a joint 
remains distended with synovia, but without pain, redness, or any other 
symptom than the swelling, and the sense of fulness, and often of weak- 
ness, which it occasions. After the subsidence of the inflammation, the 
fluid is in most instances absorbed spontaneously. When, however, this 
does not take place, the principal means adopted for promoting absorp- 
tion are, friction by the hand with any dry powder ; or rubbing the 
joint with the camphorated mercurial ointment ; or with the ointment 
of the iodide of potassium ; pressure by means of a roller, or pressure 
accompanied by the rubbing of the joint with the iodide of potassium 
ointment, which I have found to produce absorption very speedily. 
Among the most successful methods, the repeated application of blisters 
directly over the joint, if it be deeply seated, or in the immediate neigh- 
bourhood, if it be superficial, and pencilling the joint with the tincture 
of iodine, with or without its internal use, deserve to be mentioned. In 
some cases, local acupuncture has been resorted to, either as a prelimi- 
nary step to drawing off the fluid by means of the exhausted cupping- 
glasses ; or with a view to allow the fluid to escape into the surrounding 
tissue, so as to convert the case into one of diffuse oedema. 

But this procedure, if any inflammation whatever remain about the 
joint, will be of no avail in accomplishing a cure, since the fluid will be 
very quickly secreted again, and if there be no inflammation, it is unne- 
cessary, inasmuch as the disease usually yields to some of the less hazar- 
dous methods already mentioned ; but if, after the employment of other 
means, the disease should still persist, still, when it is remembered, that 
the puncturing of a joint is by no means free from the risk of exciting 
a fresh inflammatory attack, it does appear a matter of very doubtful 
propriety to recommend, for the removal of an inconvenience, a proce- 
dure, which, though it has doubtless been frequently adopted without 
such a result, may possibly excite a serious inflammation. The same 
treatment has also been proposed as for hydrocele, namely, to draw 
off the fluid, and inject tincture of iodine into the joint ; than which 
nothing could be more injudicious, or more justly deserving of unquali- 
fied condemnation. 

SCROFULOUS CHRONIC SYNOVITIS. 

This disease, called by some authors the gelatinous degeneration of 
the synovial membrane, is sometimes attributed to a slight injury, as a 
bruise, or sprain : but it often presents itself without any assignable 
exciting cause. It is most frequently met with during adolescence, 
though, certainly, it is not confined to that period. The subjects of it 
are always of a scrofulous habit ; and it is not only accompanied, but also 
preceded, in most instances, by the symptoms of scrofulous cachexy. 

Symptoms. — One of the first symptoms is, swelling about the joint, 
which slowly advances, and is of a doughy elastic nature ; but which 
cannot be said to be characterized by distinct fluctuation. This disease 
is recognised as much by its negative as by its positive symptoms, and 
is remarkable for the length of time the skin retains its natural appear- 



832 SCROFULOUS CHRONIC SYNOVITIS. 

ance. There is little or no pain, scarcely any tenderness on pressure, 
and at this stage none of the local symptoms of inflammation, except 
swelling, which, with stiffness or diminished mobility and a sense of weak- 
ness, are the only local signs of the disease. In the further progress of 
the disease the swelling continues to enlarge, and the rest of the limb 
becomes wasted. After continuing for months, and often for a longer 
period, the disease either changes favourably and the swelling dimi- 
nishes, or it goes on to suppuration of the joint, attended with great 
aggravation both of the local symptoms and of those of the scrofulous 
cachexy, and ending in the destruction of portions of the cartilages and 
bones ; and unless some of the forms of anchylosis should occur, which 
after this stage of the disease is an exceedingly rare event, the only 
chance of saving the patient's life will be the removal of the affected 
part. 

State of the Parts. — In the case of a young man, who was the subject 
of this disease in the knee, and who died of phthisis, I had an opportu- 
nity, at a post mortem examination, of making a dissection of the joint. 
I found the synovial membrane thickened, of a gelatinous appearance, 
of a grayish white colour, and at some parts considerably injected; the 
synovial fluid was flaky and much more opaque than is natural ; and 
there was an effusion of a gelatinous character into the cellular tissue, 
so that it was thickened ; and the skin, the synovial membrane, the cel- 
lular tissue, and the ligaments were all matted together. In another 
example of this disease in the knee, I lately had occasion to perform 
amputation, and found the same morbid alterations of structure as in 
the last-mentioned case, and the same matting together of tissues, with 
the additional peculiarities that the membrane was much more injected ; 
the part of it which covers the cartilages of the femur was destroyed ; 
the cartilages were removed ; the extremity of the femur was carious ; 
and the fluid in the joint was sero-purulent. 

Treatment. — Since this disease is connected with scrofula, the treat- 
ment adapted to that particular state of the constitution is, during the 
whole of its progress, indispensable ; and, however necessary local treat- 
ment may be, it is equally important to employ such means as are cal- 
culated to operate favourably on the general system. The local treatment 
is nearly the same as in simple chronic synovitis ; but with reference to 
local depletion, there are two considerations which will prevent the sur- 
geon from prescribing it, except so far as is absolutely necessary ; the 
one, that it has much less effect in controlling scrofulous than common 
inflammation ; the other, that free depletion is very unfavourable to the 
state of the general system. The treatment may be stated to consist — 
in preserving the joint at perfect rest through the entire continuance of 
the disease ; in endeavouring to arrest acute inflammation when it oc- 
curs, by rest, cold applications and local depletion, the last being em- 
ployed as sparingly as possible ; in attempting to subdue inflammation 
when more chronic, by rest and counter-irritation, slight depletion as in 
simple chronic synovitis, preceding the application of the counter-irri- 
tants ; and after the inflammation has been subdued, in employing 
means for fulfilling these three indications, namely, to keep the joint at 
rest, to apply pressure in order to promote absorption, and to use some 



INTRACTABLE DEGENERATION OF SYNOVIAL MEMBRANE. 333 

of the most efficient applications for stimulating the absorbents. These 
three indications can be effectively combined by Mr. Scott's treatment, 
which " consists in cleansing the surface of the joint with a sponge, soft 
brown soap, and warm water, and then thoroughly drying it. The part 
is then rubbed with a sponge soaked in camphorated spirit of wine, and 
afterwards covered with cerate made with equal parts of ceratum saponis 
and the ung. hydr. fort, cum camphora. This is thickly spread on 
large square pices of lint, applied entirely round the joint, and supported 
with broad strips of the emplastrum plumbi. Over these straps is placed 
an additional covering of emplastrum saponis, spread on thick leather 
and cut into four broad pieces, one for each side of the joint. Lastly, 
the whole is secured with a calico bandage, which is not to be applied 
so as to cause any uneasiness from pressure." In this and in some 
other affections of joints, the above treatment is often instituted with 
the happiest results ; but it must always be employed with the greatest 
caution, and its effects constantly watched ; otherwise very serious con- 
sequences may result. It ought never to be adopted while any inflam- 
mation exists. The pressure should at first be slight, and gradually in- 
creased at future dressings; and even while it appears to be attended 
with benefit, the symptoms must be most carefully observed, so that if 
there should, from any circumstance, be a recurrence of inflammation, 
however slight, the dressings may be immediately removed, as the pres- 
sure would be exceedingly injurious. These are the principal precau- 
tions, and it is important that they be not neglected. 

Another excellent method of fulfilling the same three indications is, 
— to excite absorption by applying pieces of lint covered with ung. hydr. 
fort, cum camphora, or equal parts of that ointment, and the ointment 
of the iodide of potassium ; to produce pressure by an elastic cotton 
roller ; and to preserve the joint at rest by a leather or wooden splint 
retained by suitable retentive appliances. 

This method I have often employed with advantage ; and it has the 
recommendation that the dressings can be removed without any trouble, 
as often as the surgeon wishes to see the appearance of the joint. If, 
unfortunately, suppuration should take place, the matter must be dis- 
charged, and the treatment formerly mentioned as proper under such 
circumstances strictly enjoined. If the desired result should not thus 
be obtained, but the patient be in danger of sinking under the continued 
irritation and discharge, the local disease must be removed either by 
excision of the joint, or amputation of the limb. 

THICKENING, WITH MORBID ALTERATION OF STRUCTURE, OR BROWN 
INTRACTABLE DEGENERATION OF THE SYNOVIAL MEMBRANE. 

This disease, sometimes called the pulpy thickening of the synovial 
membrane, is characterized by certain marks or appearances, not found 
in any other disease of the joints. The synovial membrane is converted 
into a pulpy substance of a brownish, or reddish brown colour, and of a 
thickness usually varying from a line to half an inch, but sometimes 
even exceeding an inch. This substance is not of uniform consistence, 
but is intersected in various directions by a kind of fibrous bands. 

The disease generally commences in the reflected portions of the 



334 INTRACTABLE DEGENERATION OF SYNOVIAL MEMBRANE. 

synovial membrane, and most frequently occurs in the knee joint ; but 
Mr. Hodgson met with one example of it in the ankle joint, and with 
another in one of the phalangeal articulations of the fingers. I have in 
my possession an uncommonly well-marked example of this disease 
affecting the synovial membrane of the shoulder-joint, which I took from 
a male subject brought to the anatomical rooms of this University, when 
I taught anatomy. As at that time subjects were procured by exhuma- 
tion, I found it impossible to obtain a history of the case. The whole 
of the synovial membrane is more or less affected ; at some parts it is 
about two lines in thickness, in others more than half an inch. It is of 
a light brown colour on its articular surface, and of a pulpy appearance, 
with firm intersections of a fibrous consistence. The cartilages covering 
the bones seem to be entire ; the joint contained a thick opaque fluid, 
apparently synovia, mixed with pus. No other joints than those already 
mentioned have hitherto been found affected with this disease. It oc- 
curs principally in young persons, and in adults ; but is so exceedingly 
rare after the middle period of life, that Sir Benjamin Brodie has met 
with only one example. If allowed to run its course, it may terminate 
either in suppurative inflammation followed by ulceration and complete 
destruction of the joint, or in malignant tumour. In a beautiful speci- 
men of this disease, affecting the synovial membrane of the knee joint, 
which I took from a boy named Bisset, in whose case I found it neces- 
sary to perform amputation, the whole of the synovial membrane was 
affected, except the portion which is behind the patella ; but the parts 
covering the articular cartilages of the femur and tibia were much less 
affected than that which is situated round the circumference of the joint, 
where it was in some parts an inch in thickness, and projected into the 
cavity of the articulation. The articular surface was of a very pale 
brown colour ; and the structure, when cut into, had a pulpy appear- 
ance, with white intersections of a fibrous consistence, and very much 
resembling those of carcinoma. At some few spots there were one or 
two injected vessels, but no vascular or other marks of inflammation 
could be discovered on the most careful examination ; and the impres- 
sion conveyed to me and also to some friends well qualified to judge 
was, that the change of structure was the result of some other process 
than inflammation. The ligaments were entire, and the joint contained 
a ropy fluid. 

It is remarked by Sir Benjamin Brodie, to whom we are indebted for 
first pointing out this particular disease, that, " It would add much to 
the utility of researches in morbid anatomy, if it were more frequently 
attempted to ascertain what is the first change in the organization of 
the affected part which disease produces, and from thence to trace the 
gradual progress of the other changes which take place, until the de- 
struction of the natural organization is completed." It is the opinion 
of Sir Benjamin, that this disease belongs to the same order as scirrhus 
of the breast, the medullary sarcoma or fungus nematodes of the tes- 
ticle, and numerous other diseases in which the natural structure of the 
affected organ is destroyed, and a new and different organ formed in its 
place, and that although in its progress inflammation comes on, the 
degeneration into pulpy substance with fibrous intersections is not a 



INTRACTABLE DEGENERATION OF SYNOVIAL MEMBRANE. 335 

result of common inflammation, but of a different kind of morbid action. 
Some surgeons consider the change of structure to be the result of a 
chronic form of inflammation. I have not seen a sufficient number of 
specimens at an early period of the disease to enable me to form a 
decided judgment ; but those which I have seen, and especially the ex- 
ample of it in the knee joint described above, leave no doubt in my mind 
that the opinion of Sir Benjamin Brodie is correct. 

Symptoms. — Stiffness, accompanied with a sense of weakness not 
amounting to pain, first engages the attention of the patient ; and as 
the disease advances, pain comes on, but usually it is for a long time 
inconsiderable, and is increased by exercise. Swelling is soon percep- 
tible, which has a doughy elastic feeling without fluctuation, and is irre- 
gular in shape. This elastic feeling is often very deceptive, and it is 
only after a very careful examination, under such circumstances, that 
the surgeon can satisfy himself of the absence of fluctuation. The stiff- 
ness gradually increases, and although in some instances a certain de- 
gree of mobility is retained, the joint in the great majority of cases at 
length scarcely admits of any motion. With enlargement of the joint 
there is also wasting of the limb. The disease begins very gradually, 
and for a long time its progress is slow ; but when it reaches its ad- 
vanced stages, the pain is often very great, and then its onward course 
is generally rapid. The disease, as has been already stated, may ter- 
minate either, as it usually does, in suppurative inflammation, followed 
by total destruction of the joint, or in malignant tumour, which, how- 
ever, is comparatively rare. In the former case, there will be the local 
and constitutional symptoms of suppurative inflammation ; in the latter, 
the articulation becomes much swollen, and communicates to the finger 
a sensation as if greatly distended with fluid ; the skin becomes tense, 
glistening, and prominently marked by dilated tortuous veins ; the pain 
is severe and shooting, and attended with a sense of great weight ; if an 
incision is made, blood only escapes, and the disease is now evidently 
of a malignant nature. For a considerable time constitutional symp- 
toms are not very distinctly marked ; but a modified form of hectic 
supervenes, which, however, becomes much more urgent, when the sup- 
purative crisis arrives. The patient becomes sallow, greatly emaciated, 
debilitated, and dispirited, and shows the usual symptoms of the cachexy 
attendant on malignant disease. 

Treatment. — As we are not acquainted with any treatment by which 
the natural structure of any organ after being entirely changed can be 
restored, a knowledge of the state of the parts would lead us to the 
conclusion, which the present state of our experience may be said to 
authorize, that this disease is incurable. In its early stage it may be 
somewhat palliated, and its progress rendered less rapid, by means of 
rest, attention to the general health, and cold lotions ; and the pain 
attendant on the suppurative crisis and the destruction of the cartilages 
may be considerably diminished by warm applications ; and thus a cer- 
tain degree of relief may be obtained. Sir Benjamin Brodie, after 
referring to the partial benefit derived from this treatment, says, " But 
no method, with which I am acquainted, is capable of doing more than 
somewhat checking the progress, and somewhat relieving the symptoms 
of the complaint. In every case of which I have had an opportunity of 



336 



FIMBRIATED SYNOVIAL MEMBRANE. 



seeing the termination, the ulceration of the cartilages, the formation of 
abscesses in the cavity of the joint, and the consequent disturbance of 
the patient's general health, have ultimately rendered the amputation 
of the limb necessary, in order to preseve the patient's life. At this 
period, therefore, the surgeon is called upon to recommend and urge an 
operation ; but at an earlier period it is a matter of choice with the 
patient, whether he will live with the incumbrance of a useless limb till 
the advanced stage of the disease renders its removal indispensable, or 
whether he will submit to the loss of it, before the absolute necessity 
for losing it exists." If amputation be deferred until the disease result 
in a malignant tumour, it will then be too late to derive from it any 
further benefit, than the doubtful chance of merely, for a short time, 
deferring the fatal termination. Some surgeons seem to think that at 
an early stage the disease may be cured, and they speak favourably of 
the result of treatment similar to that recommended for scrofulous 
synovitis. For my own part, having found it necessary to amputate in 
every instance which has come under my observation, I agree with Sir 
Benjamin Brodie in considering it incurable. 

FIMBRIATED SYNOVIAL MEMBRANE. 

In this disease the free surface of the synovial membrane is studded 
over with innumerable bodies termed fimbriae, of a white or yellowish 
white colour, and usually varying in size from a millet to a common pea ; 

but some are found resembling, both 
Fig. 102. in size and appearance, the appen- 

dices epiploicse of the large intestines. 
They are smooth and uniform in their 
outline, and of a glistening appear- 
ance, as if invested with a capsule of 
the synovial membrane. They are 
sometimes broad, sometimes constrict- 
ed in their base, and connected to 
the synovial membrane by a narrow 
pedicle. In some cases, these bodies 
pervade the whole articulation ; in 
others, they merely fringe the synovial 
membrane. They usually have the 
appearance of being formed of a cap- 
sule of the synovial membrane filled 
with a fatty substance, and occasion- 
ally they are somewhat of a cartila- 
ginous consistence. 

This being a very rare disease of 
the synovial membrane, little is as yet 
understood either of its causes, or of 
the nature of the morbid action by 
which the change of structure is pro- 
duced. I have seen one specimen of 
it in the museum of the University of 
Edinburgh, and three most beautiful 
specimens in the museum of St. George's Hospital, London ; of one of 




DISEASE OF ARTICULAR CARTILAGE. 3o7 

the best of which Mr. Hewitt kindly allowed an artist to take a drawing 
for me, a copy of which is here given. 

Symptoms. — Pain during and after exercise, and a grating sensation 
on moving the articulatory surfaces of the bones on each other. The 
joint becomes swollen and elastic, with stiffness and more or less limita- 
tion of its motion. 

DISEASE OF ARTICULAR CARTILAGE. 
DESTRUCTION OF CARTILAGE. 

Destruction of the substance of cartilage may take place without the 
slightest trace of disease in other structures, and as the result of actions 
confined to the cartilage itself; in which circumstances it is said to be 
original or primary ; or, it may be the consequence of acute, chronic, or 
scrofulous synovitis, or of inflammation of the portion of bone to which the 
cartilage adheres, or of scrofulous degeneration of the joint-ends of bone ; 
when it is called secondary. The destruction may thus be either original 
or secondary ; it may be extremely rapid or very slow, constituting 
acute or chronic destruction ; it may be limited or extensive ; it may be 
superficial and limited, or superficial and extensive, or it may go through 
the whole thickness of part of the cartilage, and thus penetrate to the 
bone. Though it most frequently commences on the free surface, it 
may commence in the middle of the substance of the cartilage, or, if it 
proceed from disease of the bone, on the attached surface. It may be 
unattended with the slightest vestige of disease of the synovial membrane 
or bone ; it may even be cured by the unassisted efforts of nature, with- 
out the occurrence of any new exudation, by the formation of a fibro- 
nucleated membrane from the substance of the cartilage itself ; or, it 
may lead to disease of the synovial membrane or bone, ending in total 
destruction of the joint. It is very remarkable that in all these varie- 
ties, the structural changes in the cartilage are found, on microscopical 
examination, to be similar, consisting in changes in the structure and 
arrangement of the cells, and alterations in the hyaline substance. 

When a thin slice of articular cartilage, in a healthy state, is exa- 
mined with a microscope, it is seen to consist of an apparently homo- 
geneous substance called the hyaline substance or matrix, with nucleated 
cells, named also cartilage corpuscles, disseminated through it with a 
certain order and arrangement. No blood-vessels are seen in cartilage, 
nor is there the slightest reason for believing that it contains any. 
Whatever nutrient fluid it requires, is derived from the vessels of ad- 
joining textures, and is conveyed, it is believed, through the tissue by 
imbibition. No nerves have been traced in cartilage, and it is known 
to be destitute of sensibility. From this brief description of articular 
cartilage in its healthy state, the following account of its morbid changes 
will be more intelligible. 

To Professor Goodsir and Dr. Redfern belong the merit of having 
successfully investigated the changes in the form, contents, and arrange- 
ment of the cells, and the alterations in the hyaline substance, which 
take place in the various forms of destruction of articular cartilage, and 
of having brought forward the views which are at present entertained 



338 



DISEASE OF ARTICULAR CARTILAGE. 



regarding those changes. The principal structural changes observed in 
the cells and in the hyaline substance are the following. 

As was first pointed out by Pro- 



Fig. 103. 



mm gM 



6 G>0<*2- 
9t 



fessor Goodsir, destruction of car- 
tilage is always accompanied by 
enlargement, change of form, and 
irregular arrangement of the cells. 
They become "larger, rounded or 
oviform, and instead of two or 
three nucleated cells in their inte- 
rior, contain a mass of them." 
The enlarged corpuscles at the sur- 
face burst, and discharge their con- 
tents, so that the disintegrated sur- 
face presents a series of cavities. In 
many instances the contents of the 
cells, after having been discharged, 
assist the altered hyaline substance 
in the formation of a fibro-nucleated 
membrane on the surface of the dis- 
eased portion of the cartilage. In 
such cases the nuclei become elonga- 
ted and incorporated with the fibres 
of the split-up hyaline substance ; and this is one of the most remarkable 

Fig. 104. 








I 



transformations of the nuclei which have as yet been observed. Other 
changes of the nuclei, of frequent occurrence, are their conversion into 



Fig. 103. Diseased articular cartilage, showing enlargement of the corpuscles, and the 
contents of the more superficial thrown out into the intercorpuscular substance. — Copied 
from Redfern. 

Fig. 104. Vertical section from the cartilage of the central part of the internal glenoid 
cavity of the tibia, showing the splitting into fibres on the surface. — Copied from Red- 
fern. 



DISEASE OF ARTICULAR CARTILAGE. 



339 



fatty granules, and into fat globules. The conversion of the nuclei into 
drops of oil was first described by Mr. Rainy. In cases of very rapid 
destruction of cartilage, it appears that the changes are almost entirely 
confined to the cells. 

The alterations in the hyaline substance consist of its losing its natu- 
ral homogeneous appearance, and in its being split up into bands and 
fibres, which project into the joint. These bands become incorporated 
with the liberated and elongated nuclei, and thus constitute a fibro- 
nucleated membrane, without the aid of any exudation, and by changes 
in the cartilage itself without any other texture being involved. These 
fibres constitute processes projecting into the joint, separated from each 
other at their free extremities, and at their attached extremities, con- 
tinuous with the hyaline substance. Dr. Redfern was the first to de- 
monstrate the conversion of the hyaline substance into fibres in disease 
of articular cartilage. The cartilage, during the whole of this process, 




remains non-vascular, and the membrane above referred to, is regarded 
as the result, not the cause of the destruction. If other textures become 
involved, exudation may take place from them, and the exuding matter, 
becoming pervaded by vessels derived from the involved texture, con- 
stitutes a vascular adventitious membrane in contact with the diseased 
portion of cartilage. This membrane is sometimes formed between the 
bone and the cartilage ; and there can be no doubt that to its formation 
in that position and its becoming pervaded by vessels derived from the 
bone, may be attributed the erroneous impression entertained by some 
observers, that in one form of destruction of articular cartilage, the 
destruction is preceded by the formation of vessels in the substance of 
the cartilage itself. The usual situation of the adventitious membrane 
is on the free surface, and its formation is properly attributed to the 
synovial membrane becoming involved, and giving out an exudation 
which becomes pervaded by vessels derived from itself. 

Dr. Redfern, in his work on anormal nutrition in articular cartilage, 
has given the following as the conclusions at which he has arrived in 
consequence of his investigations. 

First, — That all the known forms of disease in articular cartilages 
are connected with changes in the texture, which are essentially similar 
to each other. 

Second, — That during the progress of these changes, the cells of the 

Fig. 105. Cartilage of the patella, showing, on the surface, fibrous tissue with included 
cells and nuclei. — Copied from Redfern. 



340 DISEASE OF ARTICULAR CARTILAGE. 

cartilage become enlarged, rounded, and filled with corpuscles, in lieu 
of healthy cells ; bursting, subsequently, and discharging their contents 
into the texture on the surface ; whilst the hyaline substance splits into 
bands and fibres, and the changed hyaline substance, and the discharged 
corpuscles of the cells, afterwards form, in many cases, a fibro-nucleated 
membrane on the surface of the diseased cartilage. 

Third, — That these changes are referable only to an anormal nutrition 
as their immediate cause, and in no case to mechanical or chemical 
actions, such as attrition or digestion in a diseased secretion. 

Fourth, — That most extensive disease may go on in many joints at 
tne same time, and may proceed to destroy the whole thickness of the 
cartilage in particular parts, without the patient's knowledge, and whilst 
he is engaged in an active occupation. 

Fifth, — That the disease commences most frequently on the free 
surface ; but may proceed from the bone to affect the attached surface, 
or may take place in the middle of the thickness of the cartilage. 

Sixth, — That it is, at least, very doubtful if the symptoms which are 
believed to indicate the existence of ulceration of articular cartilages, 
are not really dependent on a morbid change in the bone. 

Seventh, — That disease of the whole thickness of an articular cartilage 
at particular parts, admits of a natural cure, by the formation of a fibro- 
nucleated membrane from the substance of the cartilage, without the 
occurrence of any new exudation. 

Favourable Results. — These vary according to the depth of the 
destruction. If only a portion of the cartilage be removed, the destruc- 
tion not extending through the whole of its depth, the diseased part 
may be healed, on the subsidence of the abnormal nutrition, by a fibro- 
nucleated membrane, formed entirely from the cartilage itself, in the 
manner already described. In such cases, the affected part, as will be 
understood from what has already been stated, presents a villous ap- 
pearance. 

If the destruction be superficial, and the synovial membrane be 
involved, there may be incorporated with the fibro-nucleated membrane 
a depressed cicatrix formed by exudation from the synovial membrane. 

When the loss of substance is to a greater depth, exposing the surface 
of the bone, or when a limited portion of the bone is removed, exuda- 
tion may take place from the vessels of the bone, and osseous granules, 
not rising to the level of the cartilage, may occupy the affected part, 
or the granules may be covered by a depressed cicatrix derived from the 
synovial membrane. 

Reproduction of cartilage never takes place, and instead of any of the 
above favourable results, the place of disintegrated cartilage may be 
occupied by an amorphous formation, technically called the porcellanous 
deposit. This substance fills up the cavity, and its smooth and polished 
surface compensates for the want of cartilage and of synovial membrane. 

If there happen to be destruction of cartilage and osseous granula- 
tions on opposite sides of an articulation, the granulations may unite, 
and a form of anchylosis be produced. Of many fine specimens of 
anchylosis in my collection, the first of the accompanying drawings 
represents one of a section of the hip joint, in which the anchy- 



DISEASE OF ARTICULAR CARTILAGE. 



341 



Fig. 106. 



losis is very perfect after the whole of the 
cartilages have been removed; the cancel- 
lated structure of the one bone is perfectly 
continuous with that of the other. The 
second drawing gives a representation of an- 
other very perfect specimen of anchylosis, 
also in my possession. The third represents 
a specimen now in my collection, given to me 
by my late friend Mr. Liston : it is represent- 
ed in his "Elements of Surgery," and in the 
second edition of Professor Miller's admirable 
work on the "Principles of Surgery." 

The above are the favourable results ; but 
in many cases, ulceration and other morbid 
changes advance so far as to involve the 
whole of the tissues, and ultimately to pro- 
duce total disorganization of the joint. 

Symptoms. — While the destruction is en- 
tirely confined to the cartilage, and the 

other tissues are perfectly healthy, the patient may experience no 
unusual sensation in the joint. When other tissues become involved, a 




Fig. 107, 



Fig. 108. 





Fig. 106. Section of anchylosis of hip joint, showing perfect union. From a prepa- 
ration in my own collection. 

Fig. 107. Perfect anchylosis of hip joint. From a preparation in my own museum. 

Fig. 108. Section of anchylosed hip joint, first delineated in Mr. Liston's " Elements 
of Surgery," and now in my museum. 



842 DISEASE OF ARTICULAR CARTILAGE. 

deep dull uneasiness in the joint, and diminished power of motion, are 
the first symptoms. The uneasiness at first is slight, not amounting, 
perhaps, to actual pain ; it is only occasional, and is often referred to 
different parts ; but it gradually becomes more severe, constant, and 
limited to a particular spot. These symptoms are believed to be coeval 
with the morbid changes in the early stages. While destruction is going 
on, the pain increases, and as the disease advances, it becomes exceed- 
ingly excruciating, especially during the night, the nocturnal exacerba- 
tions and involuntary startings of the limbs being very distressing. The 
pain, at this period, is referred to a particular spot, and is often said by 
patients to resemble the gnawing of an animal. This is supposed to 
correspond with the period of the formation of matter. Matter never 
forms, according to Dr. Redfern, until other tissues have become involved, 
and he supposes that the pain is produced by morbid changes in the 
bone, and not by the destruction of the cartilage. The pain is aggra- 
vated by motion, and also by pressure, if directed against the diseased 
portion of the joint. Sympathetic pains are also felt, which vary in 
situation according to the site of the disease, and the tenderness, on 
pressure, is not only at the seat of the disease, but sometimes also, 
although very rarely, at the parts sympathetically affected. 

Swelling is a symptom, and for the purpose of diagnosis its characters 
should be carefully observed. It is long in making its appearance, is 
slow and gradual in its increase ; and deep in situation ; it does not 
bear handling without pain ; it is nearly uniform in shape, and destitute 
of that peculiar bulging out at particular parts which is so characteristic 
of the swelling in the usual forms of synovitis ; and fluctuation, though 
for a long time obscure, becomes distinct in the advanced stage. It 
differs from the swelling in synovitis in its shape, and the time of its 
appearance, not being coeval with the pain ; and from the swelling in 
scrofulous gelatinous degeneration, which, however, it more nearly re- 
sembles in shape, in the lateness of its appearance, and in the pain 
which is felt on pressure. The swelling proceeds partly from the pre- 
sence of matter w T ithin the joint, and partly from serous infiltration into 
the external soft tissues. These secretions, as the textures . closing in 
the joint are destroyed, at length communicate, and the fluctuation then 
becomes distinct. 

The superimposed muscles become wasted, often giving rise, at an 
early period, to an unnatural form about the joint ; the whole limb 
becomes emaciated and feeble ; its circulation is weak, and there is a 
tendency to oedema. For a long time the joint is often maintained in 
a particular position, from the patient feeling in that position some 
diminution of pain; but in consequence of disorganization of the joint 
it frequently happens that 'displacement of the bones ultimately takes 
place. 

At first there may be no constitutional symptoms, but as the disease 
advances, those of inflammatory fever appear, and ultimately change to 
the symptoms of the hectic type. 

Symptoms of Destruction of Cartilage of the Hip Joint. — When the 
disease is seated in the hip joint, and proceeds to an advanced stage, it 
gives rise to pain with diminished power of motion, tenderness on pres- 



DISEASE OF ARTICULAR CARTILAGE. 843 

sure, change in the form of the nates, alteration in the length of the 
limb, and ultimately to the local and constitutional symptoms of chronic 
abscess. These symptoms present the characteristics already men- 
tioned in the description of the symptoms hitherto usually regarded as 
denoting ulceration of cartilage ; but they have also some peculiarities, 
which it may be proper to notice. 

The pain is increased by motion, or by pressure of the trochanter 
inwards, or of the limb upwards, or by any means which direct the 
pressure against the diseased portion of the joint ; and sometimes to 
relieve the parts affected as much as possible from the pressure, the 
patient maintains the limb in a position in which the ball of the femur 
is made to press least against the acetabulum. The pain is felt in the 
joint, and also at the knee, principally along its inner side ; and though 
the knee is only sympathetically affected, the pain is sometimes more 
severe there than at the hip, so that it is occasionally difficult to con- 
vince a patient that the seat of the disease is not in the knee. This is 
an exemplification of what is frequently observed, namely, that when 
disease exists at one set of terminal expansions of 'a particular nerve, 
the pain is often referred to the extremities of other branches given off 
by the same nerve ; for the anterior crural nerve gives branches to the 
hip and also to the knee ; and the trunk of the obturator nerve supplies 
the hip joint with nerves, while its anterior and posterior branches give 
nerves to the knee. 

Tenderness on pressure is felt at the hip, more especially in front of 
the joint, and posteriorly on the inner side of the great trochanter. It 
is remarkable that there is sometimes tenderness at the knee, when the 
sympathetic pain is experienced. 

The change in the form of the nates is, that they become flattened by 
the wasting of the glutei muscles from want of exercise. This is an 
early symptom, and it makes the nates appear wider than natural ; 
they feel flaccid to the touch, and their under edge is observed to be 
more loose than in the healthy state. In an advanced stage, the form 
may be still further changed by the head of the bone being drawn from 
the acetabulum upon the dorsum of the ilium. 

The alteration of the length of the limb has this peculiarity, that there 
is an apparent elongation in the early stage, and an actual shortening 
in the advanced. The balance of the pelvis being lost, the sound limb 
sustains the weight of the body, and raises up the pelvis on that side, 
while on the other, the pelvis not being supported by the diseased limb, 
falls down, and thus occasions the apparent elongation ; but it is only 
apparent, for if the measurement be taken in the early stage between a 
given point of the pelvis, and a given point in the limb on the diseased 
side, and compared with the measurement between the same points on the 
sound side, they will be found to be the same. The alteration of the po- 
sition of the pelvis may cause lateral curvature of the spine, which is often 
a consequence of this disease. It has been stated by some authors, that 
in the first stage, apparent shortening has been sometimes observed, in- 
stead of apparent lengthening. This is to be attributed to the patient 
drawing up the pelvis on the diseased side, to enable him to steady the 



344 DISEASE OF ARTICULAR CARTILAGE. 

weight of the body on the other limb ; and thus the crista of the ilium 
becomes higher on the diseased than on the sound side. 

In the advanced stage of the disease, the limb becomes shortened ; 
and in most instances, this is owing to the loss of substance and destruc- 
tion of the head of the bone, and the corresponding changes of the 
acetabulum, by which the latter becomes widened, allowing the limb to 
be drawn up by the action of the muscles, while the head of the femur 
still remains within the acetabulum. In many cases, however, the short- 
ening depends on the actual dislocation of the femur, produced by the 
action of the muscles, after the ordinary organs of relation, the liga- 
ments, are no longer able to perform their office, owing to the destruc- 
tion of the portions of bone to which they are attached. The direction 
in which the femur is dislocated is almost invariably upwards and out- 
wards, but instances have occurred where the dislocation has been into 
the ischiatic notch, or in front of the foramen ovale, or upwards and 
forwards upon the pubes. It has also been found in the cavity of the 
pelvis, of which I met with an example in a young man twenty-five 
years of age, in whose case the floor and margins of the acetabulum 
were completely removed. From the history of the case, I thought 
there was reason to believe that the destructive process had commenced 
in the soft parts. When dislocation upwards takes place, the toes are 
directed inwards ; but in other circumstances, I have almost invariably 
found the foot slightly inverted in the first stage, and, in by far the 
greater number of cases, when unattended with dislocation, slightly 
everted in the advanced stage. 

A general tumefaction takes place about the joint, and afterwards a 
swelling, which at first presents the peculiarities already described, and 
at length usually exhibits the characters of an abscess. The abscess is 
not in all cases found in the same situation, but its appearance is always 
unfavourable : for, though in children recovery has taken place after 
the formation of abscess, in adults it is almost invariably fatal ; — the 
limb becoming wasted, and ultimately oedematous, and the constitutional 
symptoms soon appearing to be those of hectic fever, with its usual train 
of consequences. 

The disease has been met with at all ages ; but it occurs most fre- 
quently between the period of puberty and the thirty-fifth year ; and it 
forms, as has been remarked, the majority of cases of hip disease among 
adults, whereas the disease of the hip most frequently met with among 
children is that which begins in the cancellated structure of the bones. 

Treatment of Destruction of Cartilage. — One of the most important 
indications during the whole progress of this disease is, to maintain the 
joint at perfect rest ; and unless this be attended to, no treatment will 
prove of any avail. The limb should be placed in the attitude which 
will be most useful to the patient in after life, and the means employed 
for obtaining immunity from motion in that attitude will vary according 
to the situation of the disease. Local depletion, especially by cupping, 
is employed, but chiefly as a precaution before using counter-irritation, 
on which the principal hope of benefit must rest. The preferable form of 
counter-irritation seems to vary according to the period of life, and to a 
certain extent according to the seat of the disease. In children, the 



DISEASE OF JOINTS BEGINNING IN THE BONE. 345 

best mode is the application of blisters; — and from my own observation, 
I am of opinion that at the commencement, a succession of small blisters 
affords the greatest relief, but that afterwards, it is better to keep up 
irritation of the blistered surface by means of some stimulating oint- 
ment. When the disease is in the wrist or the ankle, the application of 
blisters should be continued throughout, as some of the other modes of 
producing counter-irritation may be injurious to the tendons, which at 
those joints are so near the skin. 

In adults, caustic issues are preferable to blisters ; they are more 
serviceable in this than in any other disease of the joints, and the best 
method of employing them is frequently to retouch the parts with the 
caustic potass. Moxa and the actual cautery are also employed. The 
latter is very much praised by some surgeons ; but, chiefly owing to the 
difficulty of persuading patients to submit to it, I have not had sufficient 
experience to enable me to form a decided opinion from my own observa- 
tion. Of the good effects of issues I can speak with confidence. There are 
some precautions, however, which ought to be observed in the use of 
blisters and issues, namely, — not to apply them directly over the joint, 
but in its immediate neighbourhood, unless the joint be sufficiently deep 
for them to have room to act on the principle of derivation, — not to em- 
ploy them after the complete subsidence of pain, — nor to carry them so 
far as to induce general debility ; and when the symptoms of hectic 
fever appear to demand the removal of the joint, if it be in an accessible 
situation, then to discontinue them entirely for some time before ven- 
turing on such a step, lest the constitutional symptoms should be partly 
the effect of treatment carried to too great an extent. 

SCROFULOUS DISEASE OF THE JOINTS, IN WHICH THE CANCELLATED 
STRUCTURE OF THE BONES IS PRIMARILY AFFECTED. 

Morhid Changes. — According to Sir Benjamin Brodie, the first de- 
viation from healthy structure in the cancellous texture of the heads of 
the bones is, preternatural vascularity. There is also an unusual soft- 
ness in the bone, from its containing less of earthy matter than in the 
healthy condition. The cancelli are next filled with a thin, transparent 
fluid ; and, as the disease proceeds, they have a tubercular or cheese- 
like substance deposited in them. This is followed by inflammation and 
by absorption of the portion of bone between the morbid deposit and the 
cartilage, and ultimately by the destruction of the cartilage and syno- 
vial membrane : so that a communication is thus opened between the 
joint and the part containing the morbid deposit, and a portion of the 
deposit is discharged into the joint, leaving a cavern in the bone. Sir 
Benjamin Brodie says, "the cartilage ulcerates in spots, the ulceration 
beginning on that surface which is connected to the bone." On this 
subject Goodsir remarks, " In scrofulous disease of the cancellated tex- 
ture of the heads 'of bones, or in cases where the joint only is affected, 
but to the extent of total destruction of the cartilage over part or the 
whole of its extent, the latter is, during the progress of the ulceration, 
attacked from its attached surface. Nipple-shaped processes of vascular 
texture pass from the bone into the attached surface of the cartilage, 



346 DISEASE OF JOINTS BEGINNING IN THE BONE. 

the latter undergoing the change already described. It may be under- 
mined for a greater or less extent, or be thrown into the fluid of the 
joint in small detached portions, or it may entirely disappear." In all 
these changes, however, according to the views now entertained, the 
cartilage itself remains non-vascular. The ulceration of the cartilage 
and synovial membrane, and the discharge of the deposit originally con- 
tained in the bone, are followed by general synovitis, which very rapidly 
terminates in suppuration; and the contents of the joint, consisting of 
purulent matter, tubercular degeneration, and the debris of the bone, 
may ultimately be discharged by ulceration of the external soft tissues. 
Soon after the disease is fully established, and the communication is 
opened, as above described, between the diseased cavity and the joint, 
the changes within the bone are followed by effusion of lymph into the 
soft parts immediately surrounding the bone, which gives rise to a firm 
swelling ; and at a more advanced period, by effusion of serum into the 
cellular tissue, which causes slight oedema. There is, at an early stage, 
a hard swelling from effusion of lymph, and afterwards a swelling with 
fluctuation from the distension of the synovial membrane by the con- 
tents of the cavity of the joint. The skin over the swelling remains 
white, but from its natural wrinkles being unfolded, it presents a kind 
of glazed appearance ; the veins under it become large, and the parts 
above and below the joint, weak, soft, and emaciated. The scrofulous 
or tubercular deposit may be the result of previous perversion of nutri- 
tion, or a change in the liquor sanguinis exuded, in consequence of a 
slight grade of the inflammatory process ; — the change into this morbid 
deposit being believed to depend on the inherent composition or consti- 
tution of the liquor sanguinis itself. It is not regarded, therefore, as a 
disease necessarily of inflammatory origin, although as it advances, a 
process of inflammation comes to be connected with it. The above ap- 
pearances are revealed only by dissection. 

Symptoms. — Slight pain, or uneasiness scarcely amounting to pain, and 
felt only at times, and a considerable sense of weakness of the articula- 
tion, are usually the earliest symptoms. As the morbid changes advance, 
the pain becomes more severe, and is for a long time referred by the 
patient to a particular spot about the extremity of the bone. The pain 
is of a heavy, aching, bursting character, and is generally brought on by 
the heat of bed, by the dependent posture, and by motion. These 
symptoms are coeval with the changes in the bone. In the course of 
time, the pain is followed by a swelling, which at first is firm, hard, and 
unyielding, and seems to depend on enlargement of the bone ; but 
this is not really the case, for expansion of the shell of the bone rarely, 
if ever, occurs in this disease. On this subject Professor Samuel Cooper 
remarks " It was formerly a common notion that in white swellings the 
heads of the bones were always enlarged ; Mr. Russell, I believe, is the 
first writer who expressed an opposite sentiment, that he has never 
heard of an instance in which the tibia was enlarged from an attack of 
white swelling. The inaccuracy of the opinion was afterwards pointed 
out by Mr. Lawrence to the late Mr. Crowther, and the subject was 
mentioned in the earliest edition of the i First Lines of the Practice of 
Surgery.' 



DISEASE OF JOINTS BEGINNING IN THE BONE. 347 

" Deceived by the feeling of many diseased joints, and influenced by 
general opinion, I once supposed there was general, or regular expan- 
sion of the heads of scrofulous bones. But excepting occasional 
enlargement which arises from spicule of bony matter deposited on the 
outside of the tibia, ulna, &c, and which enlargement cannot be called 
an expansion of those bones, for a long time I never met with the head 
of a bone enlarged in consequence of the disease known by the name of 
white swelling. I was formerly much in the habit of inspecting the 
state of the numerous diseased joints, which were every year amputated 
at St. Bartholomew's Hospital, and though I was long attentive to this 
point, my searches after a really enlarged scrofulous bone always proved 
in vain, nor was there, at that period, any specimen of an expanded 
head of a scrofulous bone in Mr. Abernethy's museum." 

In those instances in which real enlargement of the head of a bone 
has been found, the disease did not originate in tubercular degeneration 
of its cancellous texture. In the next stage, the pain is throbbing and 
extends over the whole articulation, and the swelling is no longer con- 
fined to the situation of the bone, but is general over the whole joint, 
and presents the character of fluctuation. These symptoms are coeval 
with the inflammation of the synovial membrane. Ultimately the skin 
becomes tense, white and glistening, and is marked with dilated tortuous 
veins ; and the inflammation extending to the superimposed soft tissues, 
often gives an oedematous character to the swelling. The disease has 
already advanced to suppuration, and the matter, together with the 
debris of the bone, may be discharged through ulcerated apertures. At 
first, there is little constitutional disturbance. After some time, inflam- 
matory fever comes on, and is ultimately succeeded by hectic. This, 
like other varieties of scrofulous disease, is most incidental to young 
persons, and usually occurs before the age of puberty ; and although it 
has occasionally been found in persons in the middle period of life, yet 
it very rarely attacks any one after thirty years of age, who has not 
previously been the subject of scrofulous disease. 

Treatment. — In this, as in all scrofulous diseases, the local affection 
is very much influenced by the state of the general health, the improve- 
ment and maintenance of which becomes therefore of paramount impor- 
tance. The formation of the cheese-like deposit in the cancellated 
structure of the bone takes place at an early period, and the conditions 
most favourable to its formation are believed to be, the scrofulous dia- 
thesis, and a weak state of the general health. It is often found in 
persons of that habit who have been confined to situations where the 
air is impure, cold, or damp ; who have been excluded from free exposure 
to the light of the sun ; who have lived on a diet not sufliciently nutri- 
tious, who have not enjoyed regular exercise and fresh air ; or who 
have been subjected to any cause of debility. If the presence of the 
deposit be suspected, the endeavour must be made to limit its extent, 
and to delay the suppuration by removing the patient from the exciting 
causes of the unhealthy secretion. For that purpose free exposure in 
the open air, generous diet, the use of cod-liver oil, attention to the 
state of the skin, and the use of such medicines as, from the particular 
state of the patient, are most likely to improve the general health, must 



348 DISEASE OF JOINTS BEGINNING IN THE BONE. 

be strictly enjoined. A complete change of air, scene, and mental 
occupation, by improving the general health, is often found to produce 
the most beneficial effect on the local affection ; and, on the same prin- 
ciple, a change of residence to the sea-side, from the bracing air there 
to be found, has often been observed to lead to very favourable results. 
Tonic medicines, and more especially the preparations of iron, are 
useful ; but as permanent strength can be gained only by the proper 
assimilation of nutriment, those medicines are most likely to be useful, 
which, from the particular state of the patient, are most calculated to 
fit the digestive apparatus for the proper performance of its functions. 
As a tonic and alterative, I have often prescribed, and apparently with 
advantage, the iodide of iron. Of the preparations of iron, the vinum 
ferri of the old Pharmacopoeia, and the saccharated carbonate of iron, 
are forms often used in such cases. These means for improving the 
general health will be found most effectual tor limiting the cheese-like 
deposit, and preventing and repressing inflammation ; for in this, as in 
all scrofulous diseases, more benefit may be expected from constitutional 
than from local treatment. 

For facilitating the description of the local treatment, the disease 
may be considered in three different stages : — 

1. When it is confined to the bone ; 

2. When it extends into the articulation ; 

3. When the abscess bursts. 

In all these stages, rest is an important part of the treatment. 

In the first stage, the indications to be fulfilled are — to limit the dis- 
ease, and prevent its extending into the joint. With this view, in addi- 
tion to rest of the limb, cold applications are sometimes employed with 
advantage. Depletion by leeches, and counter-irritants, are at times 
necessary, but the employment of depletion forms no prominent part of 
the treatment. In this stage I have frequently prescribed leeches, 
when, from any circumstance, there seemed to be a fresh accession of 
inflammation, and the apparent result has been to relieve, for the time, 
the urgency of the symptoms ; but beyond this, I have never been sen- 
sible of any advantage, and in no case have I ventured on the practice 
but with reluctance. It ought always to be remembered that depletion 
has less influence in scrofulous than in common inflammation ; and that 
if carried so far as to produce an impression on the general health, it 
increases the danger of the local affection. Mild counter-irritation, to 
an extent not to affect the general health, may, in general, be resorted 
to with advantage. 

In the second stage, rest, with warm emollient applications, as poul- 
tices and fomentations, are the local remedies most likely to give relief. 

In the third stage, rest is necessary, lest any of Nature's attempts at 
anchylosis should be frustrated. Pressure should also be employed 
so far as to diminish the size of the sinuses, without obstructing the dis- 
charge of the purulent matter. If the disease continue to advance, and 
the hectic fever be to such an extent as to endanger life, amputation 
may be necessary ; but before determining on this step, the state of the 
internal organs should be carefully examined, with the view more espe- 
cially of ascertaining whether or not the patient be free from pulmonic 
and mesenteric disease ; for it may be found that the tubercular dege- 



MORBUS COXARIUS. 349 

neration is general, and, if so, there is but little probability that an 
operation would be followed by recovery. 

MORBUS COXARIUS, OR SCROFULOUS DISEASE OF HIP JOINT. 

This disease, most commonly affecting children and individuals under 
the age of puberty, is occasionally though rarely met with at a later 
period. It forms the great majority of cases of hip joint disease in 
children, and begins in the cancellated structure ; whereas the disease 
of the hip joint usually met with after puberty, and most common 
between that period and the thirty-fifth year, of which a description has 
already been given, is believed to commence with destruction of the 
articular cartilages. As the symptoms of this disease are, with certain 
exceptions which will be afterwards stated, the same as those of the 
disease of the hip joint beginning in the cartilages, and as the morbid 
changes are of the same nature as those of scrofulous disease of joints 
in which the bone is primarily affected — this being an example of that 
form of disease in the hip, — it will not be necessary to give so length- 
ened a description of certain points, as would otherwise have been 
requisite. 

Symptoms. — These have been divided by some authors into two 
stages, by Ford and others into three, and some have arranged them 
into four stages or periods, the first being what they call the period of 
invasion. In the following description we shall divide them into three 
stages. 

First Stage. — This, like some other scrofulous diseases, is of so in- 
sidious a nature, that often it has made considerable progress before its 
existence is suspected, the patient complaining for a long time merely 
of weakness and weariness of the limb, with uneasiness at the knee, but 
without any pain at the hip. This absence of pain in the affected joint 
has, in some instances, led unwary practitioners to mistake the seat of 
the disease. With these symptoms, there is a halt or slight limping in 
walking, and if the extremity be examined at this period, it will be 
found that the hip is flattened by the wasting of the glutei mnscles, the 
limb emaciated, and the affected extremity elongated ; which last phe- 
nomenon arises, as is explained by Hunter, from the pelvis being lower 
on the diseased side, in consequence of the patient supporting the body 
on the sound limb. As the disease advances, there is usually pain in 
the hip joint, though by no means so great as in the disease origi- 
nating in the cartilage ; — in some instances it is inconsiderable when 
compared with the pain at the knee. The explanation of the pain 
at the knee has been given in the section on destruction of the car- 
tilages of the hip joint. Before the termination of this stage, there 
is a sense of tension in the groin, and the lymphatic glands in that 
situation usually begin to swell. 

Second Stage.-^-The pain at the knee is much increased, and is almost 
always considerably greater than at the hip, but in the last-mentioned 
situation only, is it increased on pressure, which is an excellent guide to 
the seat of the disease. There is pain at the hip joint on concussion 
produced by striking the trochanter, the knee, or the sole of the foot. 



350 MORBUS COXARIUS. 

The pain is much aggravated by motion ; the patient supports his body 
entirely on the sound limb ; the motions of the joint are impeded, so 
that flexion and extension cannot be carried to their natural extent, and 
there is also limitation of rotation, especially of rotation inwards, any 
attempt at which gives rise to great pain. Forcible abduction also 
causes pain at the hip. There is considerable swelling about the upper 
part of the thigh, together with the other symptoms, namely, flattening 
of the hip and its consequent unnaturally broad appearance ; a lower 
position of the trochanter and fold of the hip, than on the sound side ; 
wasting of the limb, and apparent elongation of the extremity. Some 
surgeons state that real elongation takes place in this stage ; but for 
my own part, though I have given particular attention to this point, I 
have in every instance found the elongation seeming, and not real. By 
those who believe the elongation to be real, various explanations have 
been offered. Some suppose that, from the relaxation of the muscles 
and ligaments, the thigh bone is partially expelled from its socket, and 
so falls down; others, that the under part of the acetabulum being de- 
stroyed, it thus becomes wider, and the muscles relaxed ; while others 
think that the under part of the acetabulum and part of the head 
of the femur are simultaneously destroyed. I believe, however, 
that, in every instance, the lengthening will be found to be only ap- 
parent, and that if the patient be placed in a horizontal position, and a 
careful examination be made of the measurements between correspond- 
ing points of the pelvis and extremities, they will be precisely the same 
on both sides of the body. With alteration of the position of the pel- 
vis, there is often found lateral curvature of the spine. 

Third Stage. — In this stage, the swelling is larger and more painful, 
it presents the character of fluctuation, and ultimately breaks, the mat- 
ter which continues to be discharged being of an unhealthy character, 
and indicating carious destruction. Sometimes the abscess, instead of 
appearing on the thigh, has made its way into the pelvis through an 
opening occasioned by the destruction of the bottom of the acetabulum ; 
in some cases it has burst into the vagina, and in others into the rectum ; 
and occasionally it has been found to be discharged into the pelvis, and 
thence to escape through the ischiatic notch. The appearance of an 
abscess is always an extremely unfavourable symptom. In this stage, 
the extremity becomes really shortened, either, as in the disease ori- 
ginating in the cartilage, from destruction of the margin of the aceta- 
bulum, whereby the cavity becomes shallower and wider, so as to admit 
of the limb being drawn up, or from this condition combined with de- 
struction of the head of the femur, or from actual dislocation. The 
shortening is sometimes sudden, but more frequently gradual. When 
dislocation takes place, — which, however, is not always the case, — the 
head of the femur is usually, although not invariably, drawn upwards 
and outwards upon the dorsum of the ilium. In this case the trochanter 
major is drawn upwards near the crest of the ilium, and the hip is pro- 
tuberant, the swelling being produced by the upper extremity of the 
femur, and the muscles which are raised up by it. The wasted condi- 
tion of the limb makes the swelling appear greater than it really is. 
The head of the bone has been found, although very rarely indeed, dis- 



MORBUS COXARIUS. 



351 



placed in other directions ; namely, backwards, towards the ischiatic 
notch ; forwards, upon the pubes ; and downwards and inwards in the 
direction of the foramen ovale, when the extremity has been found 

Fig. 109. 




everted and elongated. There is a tendency to flexion of the thigh, 
which increases as the disease advances, and the foot is at last affected 
with oedematous swelling. 

With regard to the direction of the toes ; I have sometimes found 
them inverted in the early stage, but much more frequently everted, so 
that, judging from my own personal observation, I consider slight e ver- 
sion to be their usual position in this stage ; and after shortening has 
taken place, I have seen them sometimes still everted, with the foot 
directed nearly as it is in fracture of the neck of the thigh-bone, but 
much more frequently turned inwards, as in dislocation on the dorsum 
of the ilium. According to some authorities, when the destructive pro- 
cess is chiefly confined to the acetabulum, the head of the bone being 
comparatively little affected, the toes will be rotated inwards ; whereas 
when the head of the femur is partially destroyed, the mechanical resis- 
tance to the action of the powerful rotators outwards is in a measure 

Fig. 109. Drawing exhibiting the great shortening of the limb, and the alteration in 
the form of the hip, in the advanced stage of Morbus Coxarius, subsequent to sponta- 
neous dislocation. From a patient in my surgical wards at the hospital. 



352 



MORBUS COXARIUS. 



removed, and eversion is the consequence. The age of the patient is 
to a certain extent a guide to assist in distinguishing this disease from 
that which commences in destruction of the cartilages, but the less degree 
of pain in this disease is the principal distinction. In a very few 
instances Sir Benjamin Brodie found, in the most advanced stage, that, 
owing to a portion of bone having exfoliated so as to be loose in the 
cavity of the joint, the soft parts were so greatly irritated as to occa- 
sion constant suffering. The general health is at first but little affected ; 
after some time, slight symptoms of inflammatory fever may supervene ; 
but the formation of abscess is followed by hectic, and its usual train of 
consequences. 

Morbid Changes. — Opportunities of making dissections in the third 

stage are unfortunately numerous ; 
but as in that stage the whole arti- 
cular apparatus is involved, it is im- 
possible at that period to discover 
by dissection which structure was 
primarily affected. Opportunities 
of examining the state of the parts 
in early stages are not numerous, 
being only met with in those persons 
who have died of other diseases 
after the hip joint had become affect- 
ed. From examinations, h^vever, 
which have been made in such cir- 
cumstances, there is reason to con- 
clude that this disease begins in the bone — that the morbid changes are 



Fig. 110. 




Fig. 111. 



Fie. 112. 




of the nature described in the section on scrofulous disease of joints 



Figs. 110, 111, 112. Every stage of Morbus Coxarius, exhibiting tubercular deposit 
in the substance of the bone forming the acetabulum, and in the head of the femur. 
On the articular surfaces of both bones various irregularities and hollows are observed 
leading to masses of the deposit. The patient died of inflammation of the brain, 
which afforded an opportunity of verifying the diagnosis made during life. From 
preparations in my museum. 



MORBUS COXARIUS. 353 

beginning in the cancellated structure — that in the majority of cases 
the os innominatum is primarily and most extensively affected — that it 
sometimes begins in the femur, and that occasionally the morbid action 
commences contemporaneously in both bones. The first deviation from 
the healthy condition is, that, according to Brodie, part of the can- 
cellated structure becomes preternaturally vascular — that at an early 
period the affected part becomes unusually soft from a deficient propor- 
tion of earthy matter, and then a thin fluid is deposited in the cancelli. 
These changes constitute the anatomical characters at an early period 
of the disease. As the disease advances, the bone becomes still softer, 
and, instead of a thin fluid, a cheese-like substance is deposited in the 
cancelli, and, in many instances all traces of cancellous structure disap- 
pear, its place being occupied by the cheese-like substance, as several 
beautiful specimens in my own collection demonstrate. According to 
the views now entertained, the scrofulous deposit may be the result of 
previous perversion of nutrition, or a transformation of liquor sanguinis, 
exuded in consequence of a slight grade of the inflammatory process. 
In the progress of the disease, the structures between the deposit and 
the joint undoubtedly become involved in a process of inflammation ; and 
as a result of this, a communication is established with the cavity of the 
articulation, and the whole articular surface becomes the subject of the 
morbid changes described in the section on scrofulous diseases of the 
joints beginning in the cancellous structure, which changes it is unneces- 
sary here to repeat. That an inflammatory process occurs in the pro- 
gress of the disease, all agree ; but as to the nature of the morbid action 
of which the cheese-like deposit is a result, there has been a difference of 
opinion. Sir Benjamin Brodie, Lloyd, Bust, and others, regard the 
deposit as a product of inflammation, while others think it may be a 
result of perverted nutrition or secretion unconnected with inflammation, 
or a transformation of liquor sanguinis exuded in consequence of inflam- 
mation. 

From many facts which have been ascertained, there seems reason to 
conclude, that in scrofulous constitutions, tubercular deposits in certain 
textures are results of inflammation, and their increase may be arrested 
if the inflammation be subdued ; but it seems equally certain from many 
observations, and from the history of many cases, that when the consti- 
tutional diathesis is very decided, they may take place wherever there 
is any congestion of blood, and even sometimes where there is no trace 
whatever of any congestion, inflammation, or any disturbance of the 
circulation. In a practical point of view, this is not a matter of very 
great importance to determine with reference to the cheese-like sub- 
stance in this disease : for it is generally allowed that depletion has less 
control over scrofulous than over common inflammation ; that when 
adopted to any great extent in persons of a scrofulous diathesis, it is 
very injurious ; and further, that even if the first deviation from a 
healthy condition -were a consequence of a low grade of inflammation, it 
could scarcely be expected that the inflammation within the bone could 
be much affected by any extent of depletion, which it would be safe or 
judicious to allow. The scrofulous diathesis of the individuals in whom 
these depositions occur, is no doubt hereditary, and is believed to 

23 



354 MORBUS COXARIUS. 

depend, in part at least, on a peculiarity in the condition of the blood. 
The tendency to these depositions is increased by habitual low diet, 
deficiency of fresh air and exercise, residence in a low damp situation, 
want of free exposure to the light of the sun, debility from great 
evacuations or other causes, disorder of the organs of digestion, and 
habitual mental depression. 

These considerations are important in a practical point of view, and 
show how needful it is for individuals who have a tendency to these 
depositions, to pay attention to diet, to live in a dry bracing atmo- 
sphere, with exposure to the light of the sun, — to be careful as to the 
proper regulation of the digestive apparatus, and to cultivate habitual 
cheerfulness. When the blood is morbidly defective of fibrine, exuda- 
tion of albuminous matter seems very apt to take place on the occur- 
rence of local congestion or inflammation ; and in many instances it 
has been found even where no trace whatever exists of any disturbance 
of circulation. I have, in my own collection, many specimens in which 
bones are almost entirely filled with cheese-like deposit, where the 
outer encasement of bone is very thin, and no trace whatever dis- 
coverable of increased vascularity, but quite the contrary. The diminu- 
tion of vascularity, after the occurrence of deposit, has been remarked 
by others. 

Treatment. — After what has been already stated regarding the treat- 
ment of disease of joints, beginning in the cancellated structure, it 
seems unnecessary to give any lengthened remarks on the treatment of 
morbus eoxarius. As the maintenance of the general health is a para- 
mount indication, every judicious and available means for that object, 
consistent with the fulfilment of other necessary indications, must be 
adopted, their use being modified according to the particular circum- 
stances of the case. The feeble state of the patient's constitution will 
scarcely admit of antiphlogistic treatment ; but antiphlogistic regimen 
may be necessary until the inflammatory symptoms have been subdued. 
"Local abstraction of blood," Mr. Liston remarks, "is seldom at all 
required, and its employment in cases of morbus eoxarius in weak con- 
stitutions, which it generally seizes upon, is very questionable." The 
most important parts of the local treatment are, the strict observance 
of rest, and the employment of counter-irritation ; for which latter pur- 
pose blisters, setons, issues, moxa, the potential and the actual cautery, 
have all been used. We find that in the time of Hippocrates, counter- 
irritation by the actual cautery, was employed in this disease, and in 
modern times some consider it preferable to other means. For my own 
part, I have followed the method recommended by Sir Benjamin Brodie 
in disease of the hip-joint, namely, the employment of blisters in 
children and issues in adults^ which he makes by the application of the 
potential cautery, and keeps open by repeatedly touching the issue with 
caustic. 

The best situations for issues are the hollow between the trochanter 
major and the tuberosity of the ischium, and the outside of the joint 
near the situation of the tensor vaginas femoris. Issues ought never to 
be employed to such an extent as to be a cause of debility, and they 
should be at once discontinued on the appearance of undoubted signs 



MORBUS COXARIUS. 355 

of the existence of abscess. In recent cases, blisters usually give con- 
siderable relief. With regard to the treatment of abscess in this dis- 
ease, much difference of opinion prevails. Some surgeons, thinking 
that the urgent symptoms of hectic come on more quickly when an 
opening is made than when the abscess is opened by nature, do not 
approve of making an opening, except when there is uncontrollable 
pain, with great tension of the soft parts ; some recommend that an 
opening be made at an early period ; while others advise that unless 
there be great constitutional disturbance, it be deferred until the soft 
parts become thin in consequence of interstitial absorption. When it 
is evident that matter has formed, and is beginning to make its way to 
the surface, it appears to be the preferable plan, on the whole, to make 
an incision, by which means considerable suffering may be prevented, 
and the extent of disorganization limited. On this subject Sir Benjamin 
Brodie remarks : — " An abscess connected with any joint, but particu- 
larly one connected with the hip, does not form a regular cavity, but 
usually makes numerous and circuitous sinuses in the interstices of the 
muscles, tendons, and cellular tissue, before it presents itself under 
the integuments. It is, therefore, less easy to evacuate its contents, 
than those of an ordinary lumbar abscess, and, indeed, it can seldom 
be emptied without handling and compressing the limb, in order to 
press the matter out of the sinuses in which it lodges. But this is often 
attended with very ill consequences. Inflammation takes place of the 
cyst of the abscess, and pus is again very rapidly accumulated. Small 
blood-vessels give way on its inner surface, the bloody discharge of 
which, mixed with the newly-secreted pus, goes into putrefaction, and 
exceedingly disturbs the general system. I have seen cases where, 
after a good deal of pains taken to obtain the complete evacuation of 
the contents of the abscess, and the puncture having healed, in a few 
days the tumour has become as large as ever, attended with pain in the 
limb, and a fever resembling typhus in its character, and threatening 
the life of the patient. A second puncture having been made, a quan- 
tity of putrid foetid pus, of a reddish brown colour, has escaped ; the 
confinement of which had produced all the bad symptoms, which have 
been immediately relieved by its evacuation. The practice which has 
appeared to me to be on the whole the best, is the following : — An 
opening having been made with an abscess lancet, the limb may be 
wrapped up in a flannel wrung out of hot water, and this may be con- 
tinued as long as the matter continues to flow of itself. In some in- 
stances, after a short time the discharge ceases, the orifice heals, and 
the puncture may then be repeated some time afterwards ; but when 
the puncture has not become closed, I have never found any ill conse- 
quences to arise from its remaining open. On the contrary, I have no 
doubt that it is desirable that the wound should not heal, until the 
abscess has contracted, granulated, and healed from the bottom ; and 
this is one reason ibr making, not a small puncture, but a free opening 
with an abscess lancet, or double-edged scalpel. Another reason for 
proceeding in this manner is, that when the puncture is small, the 
abscess cannot discharge the whole of its contents. Wherever this 
happens, the suppuration is much greater than it would have been, if 



356 ANCHYLOSIS. 

the matter could have flowed out as fast as it was secreted. A profuse 
discharge from an abscess is an almost certain indication that there is 
a lodgment of matter in some part of its cavity. Such a lodgment pro- 
duces an effect on the secreting surface of an abscess, similar to that 
which a pea produces in an issue, and it should, if possible, be pre- 
vented." 

[anchylosis. 

Anchylosis is a term now used to imply stiffness of the joint without 
reference to the limb being straight or bent, though the word *y*0Aor 
signifies crooked. 

The forms of this affection are various, and numerous divisions may 
be made, based upon different conditions of the joint. The immobility 
may be partial or complete ; it may depend upon changes which have 
taken place either in the soft parts or in the bone ; it may be that these 
changes have taken place either within or without the capsule of the 
joint. 

False anchylosis is that stiffness resulting from changes in the soft 
parts, particularly in the fascia, tendons, and ligaments. It is often 
induced by keeping the joint at rest for a long time, as is frequently 
the case after injuries. 

Inflammation in the neighbourhood of the joint is, however, a more 
frequent cause. Effusion of lymph takes place either in the superficial 
or deeper structures of the joint, and agglutination necessarily follows. 
True anchylosis is generally the result of some disease within the 
capsule of the joint, commencing in the synovial membrane or cartilage. 
The stiffness is complete, and is owing to a fusion of the articular extre- 
mities of the bones, which occurrence is often favourably considered by 
the surgeon, especially if not attended with curvature, since it indicates 
a termination of the original disease. 

Rest is also a cause of true anchylosis, and this principle is con- 
stantly employed in the treatment of those diseases, where the cure is 
dependent on fusion of the bones, for instance in coxalgia (see Fig. 108), 
and caries of the spine. 

Treatment. — The mode of treatment will in a great measure depend 
upon the nature of the affection. 

In cases of false anchylosis, attended with bending of the limb, 

passive motion must first be at- 
tempted, but if no motion can be 
produced, machinery must be 
resorted to. Dr. Mutter's splint, 
a modification of Stromeyer's 
screw, will be found a most effec- 
tual means of making gradual 
extension and flexion. 

In the application of this or 
any other mechanical means, 
care must be taken that the ex- 
tension be very gradual, for fear 
of exciting inflammation. The 
screw should be turned a few 




HYSTERICAL AFFECTION OF THE JOINTS. 357 

threads every day, until the limb is straightened, after which its action 
must be reversed, and the limb brought back to its original position. 
Flexion and extension should be made every day, and the joint should 
be rubbed with stimulating liniments. In addition to friction, benefit 
will also be derived from steam or vapour baths. 

But should these means prove unavailing, and the rigidity seem to 
be dependent upon one or more tendons, they may be divided by a 
narrow-bladed knife subcutaneously. 

In making the incision, the knife should be so directed as not to cut 
any important nerve or blood-vessel. After the division, extension is to 
be made with splints, and gradually increased from day to day, by 
means of the screw. 

In cases of true or bony anchylosis no treatment will be necessary, 
unless the union of the bones is so angular as to deprive the patient of 
the use of an important limb. In such cases the operation of Dr. J. 
Rhea Barton is to be performed. It consists in sawing out a wedge- 
shaped piece of bone, and establishing a false joint, or if that should 
fail, reunion is to be effected with the bone in an extended position. 
Dr. Barton successfully performed this operation at the hip in 1827, 
and on the knee in 1838. Dr. Gibson, of the University of Pennsylva- 
nia, has also successfully performed the operation at the knee. 

HYSTERICAL AFFECTION OF THE JOINTS. 

Hysterical females often complain of great pain in the joints, which 
might be mistaken for some real and dangerous disease of the part. 
According to Brodie, " At first there is a pain referred to the hip, 
knee, or some other joint, without any evident tumefaction ; the pain 
soon becomes very severe, and by degrees a puffy swelling takes place, 
in consequence of some degree of serous effusion into the cells of the 
cellular texture. The swelling is diffused, and in most instances trifling ; 
but it varies in degree ; and I have known, where the pain has been 
referred to the hip, the whole of the limb to be visibly enlarged from 
the crista of the ilium to the knee. There is always exceeding tender- 
ness, connected with which, however, we may observe this remarkable 
circumstance, that gently touching the integuments in such a way as 
that the pressure cannot affect the deep-seated parts, will often be pro- 
ductive of much more pain than the handling of the limb in a more 
rude and careless manner. In one instance where there was this ner- 
vous affection of the knee, immediately below the joint, there was an 
actual loss of the natural sensibility ; the numbness occupying the space 
of two or three inches in the middle of the leg. Persons who labour 
under this disease are generally liable to other complaints, and in all 
cases the symptoms appear to be aggravated, and kept up by being 
made the subject of constant anxiety and attention." 

Treatment. — Unfortunately for the patient, this affection is sometimes 
treated for a diseased or injured joint by antiphlogistic measures, which 
necessarily aggravate the symptoms. Constitutional remedies are those 
to be relied on. All of the functions are to be restored to a healthy 
condition, particularly the menstrual and digestive, since these will be 
usually found at fault. 



358 HYSTERICAL AFFECTION OF THE JOINTS. 

I 

Hygienic remedies are more valuable than local. " The patient 
should have fresh air, generous living, and plenty of occupation for 
mind and body ; she should be encouraged to take exercise, notwith- 
standing pain and weakness ; and to resume, as far as possible, the 
habits of a healthy person." The shower-bath and frictions of the 
skin will improve the capillary circulation. Tonics, such as quinine, 
valerian, and iron, will be found most valuable where there is debility. 
Brodie has also found benefit in the use of assafoetida injections, and in 
the enveloping thejoint with a plaster composed of equal parts of ex- 
tract of belladonna and soap plaster. — Ed.] 




359 



CHAPTEK X. 
CURVATURES OF THE SPINE. 

All curvatures of the spine may be comprehended under one or other 
of the three following heads : — 

I. That in which the spine presents some unnatural curvature either 
backwards or forwards ; 

II. That in which there is an unusual deviation from the mesial line, 
forming one or other of the varieties of mesial curvature ; 

III. That in which there is a combination of both the preceding con- 
ditions, which is denominated mixed curvature. 

The curvatures of the first class are subdivided into three varieties : — 

1st. Angular curvature ; 

2d. Posterior curvature, or excurvation ; 

3d. Anterior curvature, or incurvation. 

Some authors confound the terms excurvation and incurvation. 

ANGULAR CURVATURE. 

Though Mr. Liston says — " the lumbar vertebrae are those most fre- 
quently affected," most authorities agree with Stafford in the opinion 
that this disease appears most frequently in the dorsal region. " An- 
gular curvature," Mr. Stafford remarks, "may occur in any part of the 
vertebral column, in the cervical, the dorsal, and the lumbar vertebrae. 
It, however, most frequently takes place in the dorsal vertebrae, as they, 
from the manner in which they are impacted together with their carti- 
lages, which are much thinner in front than behind, and from their 
natural inclination to bend forward, are more favourable to it than any 
other part of the spine ; hence, disease of the cervical or lumbar verte- 
brae may go on to a considerable extent before curvature forwards will 
take place, the reverse arrangement of the cartilages occurring, and 
these parts of the column naturally bending backwards, whilst disease 
in the dorsal vertebrae, from the weight of the trunk being particularly 
upon them, and the curve being forwards naturally, would proceed more 
rapidly." 1 All. agree that the progress of the disease is most rapid, and 
its appearance earliest in the dorsal vertebrae ; for in the cervical and 
lumbar regions the vertebrae and intervertebral substances are deeper 
before than behind, the reverse of which is true of the dorsal regions. 
In the former, therefore, very considerable destruction must take place 
before the spine can lose its natural convexity in front and become con- 

1 Stafford's Treatise on the Spine, p. 164. 



360 CURVATURES OF THE SPINE. 

cave ; but in the latter, the spine being naturally concave in front, an- 
gular curvature will be produced by a destruction much less extensive 
than in the cervical and lumbar regions, but especially the lumbar. This 
form of curvature is more frequent in the cervical than in the lumbar 
region, and more frequent in the dorsal than in the cervical. It may 
occur at any period of life, though it is much more commonly met with 
in young persons, and seldom commences after the age of puberty, ex- 
cept when induced by some particular disease. 

In treating of many injuries and diseases, we have considered first 
the causes, next the symptoms, then the state of the parts, and lastly 
the treatment to be employed ; we shall here adopt a somewhat different 
arrangement, and refer first to 

The state of the Parts. — Angular curvature may arise from one or 
other of the five following causes : — 

I. It may be the consequence of scrofulous caries of the spine. The 
bodies of the vertebras, from their spongy texture, are peculiarly liable 
to this disease. It is unnecessary to trace the progress, or explain 
minutely the nature of the local changes which precede the occurrence 
of scrofulous caries. According to some authorities, the firafc deviation 
from the healthy condition is, that part of the cancellated structure be- 
comes preternaturally vascular ; that at an early period the affected 
part becomes unusually soft from a deficient proportion of earthy matter, 
and that a thin fluid is deposited in the cancelli. These changes con- 
stitute the anatomical characters at an early period of the disease. As 
the disease advances, the bone becomes still softer, and instead of a thin 
fluid, a cheese-like substance is deposited in the cancelli. Sometimes 
the substance occupies only the cells, while the cancellous structure still 
remains ; sometimes the cancellous structure of a part of the bone is re- 
moved, and its place occupied by the scrofulous substance, and some- 
times the whole of the cancellated structure of a vertebra has been found 
to be absorbed, and caseous matter deposited in its stead. I have in 
my own collection a vertebra, the whole cancellated structure of which 
has been absorbed, and replaced by cheese-like matter retained in its 
place by an exceedingly thin shell of bone. This variety, in the quan- 
tity and extent of deposit, corresponds with what is observed in other 
bones affected with this disease. When the disease, for example, is 
situated at the joint ends of bones, the deposit is usually very limited ; 
but in a long bone the same substance is sometimes found to occupy the 
whole of its interior. I have specimens in which the whole of the femur 
is occupied with this substance, contained within a very thin encasement, 
which is formed by the outer part of the original shell of the bone. 
That an inflammatory process occurs in the progress of the disease all 
agree ; but as to the nature of the morbid action of which the caseous sub- 
stance is the result, there is a difference of opinion. According to the 
views now entertained, the scrofulous deposit may be the result of pre- 
vious perversion of nutrition, or a transformation of liquor sanguinis 
exacted in consequence of a slight grade of the inflammatory process. 

From many facts which have been ascertained, there seems reason to 
conclude that in scrofulous constitutions, caseous deposits in certain 



CURVATURES OP THE SPINE. 361 

textures are results of inflammation, and their increase may be arrested 
if the inflammation be subdued ; but it seems equally certain from many 
observations, and from the history of many cases, that when the con- 
stitutional diathesis is very decided, they may take place wherever there 
is any congestion of blood, and even sometimes, where there is no trace 
whatever of any congestion, inflammation, or any disturbance of the 
circulation. In a practical point of view, this is not a matter of very 
great importance to determine, with reference to the cheese-like sub- 
stance in this disease ; for it is generally allowed that depletion has less 
control over scrofulous, than over common inflammation, that when 
adopted to any great extent in persons of a scrofulous diathesis, it is 
very injurious ; and further, that even if the first deviation from a 
healthy condition were a consequence of a low grade of inflammation, it 
could scarcely be expected that the inflammation within the bone could 
be much affected by any extent of depletion, which it would be safe or 
judicious to institute. The tendency to this deposit is believed to 
depend, in part at least, on a peculiarity in the condition of the blood, 
which is unusually serous. When the blood is morbidly defective of 
fibrine, exudation of albuminous matter seems very apt to take place on 
the occurrence of local congestion, or inflammation ; and in many 
instances it has been found, even where no trace whatever exists of any 
disturbance of circulation. I have, in my own collection, many speci- 
mens in which bones are almost entirely filled with the caseous deposit, 
where the outer encasement of the bone is very thin, and no trace what- 
ever discoverable of increased vascularity, but quite the contrary. The 
diminution of vascularity, after the occurrence of deposit, has been 
remarked by others. 

The deposition is succeeded by a low grade of inflammation of the 
bones and intervertebral substances, which ultimately terminates in 
caries ; and, in consequence of destruction of the bodies of the vertebrae, 
as well as of the intervertebral substances, the sound part, above the 
portion destroyed, falls forward on the part below, and thus gives rise 
to angular curvature. The commencement of the destruction is almost 
invariably towards the anterior parts of the bodies of the vertebrae, but 
sometimes, though very rarely, on their posterior aspect ; in this case 
the parts which naturally furnish attachment to the arches are destroyed, 
and a separation takes place between them and the remaining portions 
of the bodies of the vertebrae. In my own collection there is a particularly 
interesting preparation illustrative of this fact. In this preparation, 
destruction has taken place of the posterior surfaces of the bodies of 
certain vertebrae, so that the arches and transverse processes are de- 
tached, the anterior portions of the bodies remaining entire. There is 
no breach of continuity along the front of the column, but there is a 
large chasm in its posterior portion, communicating with the vertebral 
canal. There was no curvature in this case ; for the anterior parts of 
the vertebrae being entire, there could not have been angular curvature 
with the projecting angle backwards, nor could there have been angular 
curvature with the projection forwards ; for, though the arches were 
detached from the bodies, the spinous processes and the arches remained 



362 



CURVATURES OF THE SPINE. 



impacted together, and prevented the spine from presenting a concavity 
along its posterior aspect. There is considerable variety as to the rela- 
tive position of the two extremities of the diseased portion ; sometimes 
the upper part falling forward, comes to be directly in contact with the 
under part ; sometimes it is otherwise ; but this will depend upon the 
number of the bodies of the vertebrae destroyed, and the extent of the 



Fig. 114. 



. Fig. 115. 




destruction backwards. As the bodies of the vertebrae and the inter- 
vertebral substances form the part of the column which supports the 
superincumbent weight, when a chasm or gap is produced in front, the 
superincumbent weight sends the upper part forward, producing incur- 
vation in front of the spine, and projections behind of the spinous pro- 
cesses, and, from the incurvation being of an angular form, the disease 
is denominated angular curvature. The spinal cord traverses the spinal 
canal, having its sheath in contact with the arches, and not the bodies 
of the vertebrae : that is to say, it directs its course along the greater 
curve. In most cases of decidedly marked angular curvature, complete 
or partial interruption of the functions of the spinal cord comes on 
sooner or later ; the portion of the cord at the affected part of the spine 
is as far as possible from the bodies in front of it ; but still, the bones 
do in some cases press upon the cord, and interrupt its functions, espe- 
cially w T hen the destruction has been rapid, and the curve is very abrupt. 
This cause of pressure and consequent paralysis may not be permanent. 
The projecting portions of bone may ultimately become smoothed down 
by absorption, and in some cases, this no doubt explains the discon- 
tinuance of the paralysis. The functions of the cord may also be inter- 
rupted by pressure upon the membranes, produced by matter formed in 
the progress of the disease. These are the causes, external to the 
membranes, which may occasion pressure on the cord and interrupt the 
due performance of its functions. The same interruption, however, is 

Fig. 114. Remarkable example of angular curvature and anchylosis. From a prepa- 
ration in my museum. 

Fig. 115. Angular curvature from caries. From a preparation in my museum. 



CURVATURES OF THE SPINE. 363 

often produced by results of inflammation, with which the membranes 
or the cord, or sometimes both become affected ; and in such cases there 
is usually found on dissection, a thickened condition of the membranes, 
or the formation of matter between or within them, or a preternaturally 
injected state of the cord, or a softened condition of it, which may vary 
in degree from a slight deviation from the healthy appearance, to that 
state in which it is almost entirely fluid. Paralysis, however, has been 
known to exist where none of the above conditions, nor any morbid 
alteration of structure, was discovered on dissection ; and Stafford and 
others suppose that it is sometimes to be referred to longitudinal corn- 
pressure of the anterior portion of the medulla. " The effect of angular 
curvation," Mr. Stafford remarks, "is the bending of the medulla and 
its membranes ; which, as I have before stated, causes a greater or less 
degree of paralysis of the parts below, which, however, does not always 
arise from pressure of the bones upon it, but from the bending of its 
own substance, producing pressure upon itself ; for instance, the ante- 
rior portion of the medulla would be compressed, while the posterior 
portion or back of it would be stretched." 

It may be regarded as a general law, that of the two functions, volun- 
tary motion and sensation, the former is almost invariably first removed, 
and the latter first restored ; the rationale of which is, that the anterior 
columns of the spinal cord, which give off the anterior roots of the nerves, 
by which they preside over voluntary motion, are nearer to the seat of 
the disease, and therefore more exposed to pressure than the posterior 
columns which give off the roots presiding over sensation. Although 
pressure on the spinal cord is usual in angular curvature, it is surprising 
how nature, even in some cases where the destruction is very great, 
and the deviation from the natural form of the spine very remarkable, 
yet continues to maintain the integrity of the vertebral canal, so as 
to preserve the cord from being compressed. Of many examples of 
this remarkable fact I shall only refer to the following : Mr. Stafford 
mentions the case of a child in whom, though the bodies of six dorsal 
vertebrae were destroyed, and the angle of the curve was very acute, 
paralysis did not occur. Professor Cruveilhier gives the particulars of 
a case in which the bodies of five dorsal vertebrae were completely 
destroyed ; where the fifth dorsal vertebra rested on the eleventh, the 
two becoming anchylosed, and at a very acute angle ; and yet the 
medulla was preserved free from pressure. I have at present under 
my care a girl ten years of age, in whose case the bodies of the fourth, 
fifth, sixth and seventh dorsal vertebrae must be entirely removed ; an 
abscess is formed, and is pointing about the middle of the seventh rib ; 
and judging from the appearance of the spine behind, the parts above 
and below the seat of the disease must be for a short distance almost 
parallel with one another, so abrupt is the curve ; and still the patient 
is as yet quite free from any symptoms of compression of the spinal 
cord. The only explanation given of such cases is that the process of 
destruction must have been very slow, and the deviation from the natural 
form extremely gradual. Mr. Stafford remarks, " The completeness and 
incompleteness also of the symptoms very much depend upon the rapidity 



364 CURVATURES OF THE SPINE. 

■with which the curve takes place. If the destruction of the bodies of 
the vertebrae has been very quickly effected, the paraplegia is usually 
more complete ; but if it has been slow in its progress, the paralysis 
below is often very imperfect." 

In the progress of the disease, a collection of purulent matter forms, 
as in scrofulous caries in other bones, constituting what in some instances 
has been denominated lumbar or psoas abscess, but more properly spinal 
abscess. The appearance of abscess is an exceedingly unpromising 
symptom ; it is, indeed, generally regarded as fatal. The period at which 
suppuration takes place differs greatly in different examples of this dis- 
ease ; in some it occurs at an early period, in others not for many 
months, or even for a longer period ; and indeed an abscess is some- 
times retained for years by the neighbouring parts becoming thickened 
and matted together. As a general law it may be stated, that the sup- 
puration is much earlier when the curvature is induced by scrofulous 
caries than when it arises from ulceration of the cartilages. The situa- 
tions in which such collections point are various. When the abscess is 
connected with the cervical vertebrae, it may present itself among the 
muscles on the side of the neck, which is most usual, or it may be 
directed forwards, and burst into the pharynx, of which I have seen one 
example. When the abscess is connected with the dorsal division of 
the spine, it may present itself along the lateral part of the thorax, of 
which I have already mentioned one example, or it may point at other 
aspects of the parietes of the thorax by running along some of the 
intercostal spaces ; but usually the matter follows the course of the 
posterior mediastinum, escapes under the diaphragm, and then descend- 
ing along the course of the psoas muscle points in the groin. Sometimes 
an abscess in the dorsal division forms a large swelling on the side of 
the abdomen, the matter descending between the peritoneum and the 
other structures which constitute the abdominal parietes ; and I had an 
opportunity of making a dissection in a case of curvature from scrofulous 
caries of the 7th, 8th, and 9th dorsal vertebrae, in which a spinal abscess, 
after following the course first of the mediastinum, and then of the psoas 
magnus, burst at last into the under extremity of the sigmoid flexure of 
the colon. When the abscess is connected with caries of the lumbar 
vertebrae, it most commonly points in the groin near the insertions of the 
psoas magnus and iliacus internus muscles, or somewhere in the thigh 
below Poupart's ligament. In some instances, the abscess has shown 
itself in the loins, and in others in the nates, but these are compara- 
tively very rare occurrences. The only favourable termination which 
can take place in this disease is anchylosis, to which, however, the soft 
condition of the bones is by no means favourable. 

II. Angular curvature may result from destruction of the interverte- 
bral substances, — the disease thence extending to the bodies of the 
vertebrae. 

III. It may arise from chronic inflammation commencing in the 
vertebrae, followed by ulceration and caries ; the vertebrae being like 
other bones, liable to inflammation. Such inflammation may be of a 
common character causing common caries ; or of a scrofulous character 



CURVATURES OF THE SPINE. 365 

producing scrofulous caries already referred to, or of a rheumatic 
character, which may end in what has been denominated rheumatic 
caries. Destruction of the intervertebral cartilages is believed to be an 
early consequence of inflammation of the bodies of the vertebrae. 

IV. It may originate in the softening and absorption of a vertebra 
without the production of any chasm. I have in my collection two very 
striking specimens of this condition, in both of which the curve is very 
abrupt, and yet there is no chasm or any trace of inflammation dis- 
coverable ; and I have had under my care for two years a girl with 
angular curvature in the middle of the dorsal region, which case, from 
the entire absence throughout of any symptom whatever, except the de- 
viation from the natural form of the spine and the consequent alteration 
of the form of the chest, I consider to be one of this nature. 

V. According to some surgeons, it may arise from inflammation of 
the investing membrane of the vertebrae. Mr. Tuson, after referring to 
some of the more common causes of angular projection, says, " From 
observations I have made, and numerous cases whiqh have come under 
my care, I have formed a conclusion, that it may also arise from inflam- 
mation commencing in the membrane that covers the upper and lower 
surfaces of the bodies of the vertebrae, connecting the intervertebral 
substances with the bone, and then extending itself into that substance 
and cancellated structure." 

Symptoms. — These are divided into two stages : — 

1st. Before curvature ; 

2d. During and after its formation. , 

In the first stage, the patient complains of a sense of weakness at the 
part of the back affected, and of weariness, and is unwilling to take ex- 
ercise. After some time, a dull heavy pain is experienced during and 
after exercise. The pain, which at first is slight, becomes afterwards 
more severe, and is increased by exercise, by any sudden jerk commu- 
nicated to the spine, and generally by percussion, and relieved by the 
horizontal position. From irritation of the spinal cord, there is often 
an altered sensation or occasional feeling of pain in the lower extremi- 
ties ; occasionally spasmodic twitches of the muscles, and at times 
spasmodic rigidity of the limbs. In the progress of the disease, and 
before the second stage, the muscles become wasted and lose the power 
of readily obeying the will, in consequence of which the patient cannot 
easily and quickly place his foot exactly on the spot where he may wish 
to place it ; and when he walks he is very apt to trip. There is cold- 
ness of the extremities, and fulness and tightness in the epigastric re- 
gion ; patients in this state often complain of chilliness, and they are 
usually found to exhibit symptoms of a feeble condition of the general 
health. In the second stage there are found the local symptoms of the 
first stage, often in an increased degree, and together with these, cur- 
vature, at first slight, but gradually increasing, and in a form very 
abrupt, — a peculiarity most important to be remembered, as it is one of 
the best guides for distinguishing angular curvature from some curva- 
tures which depend on a different condition, and in which, although the 
spine is bent backwards, the curve, instead of being abrupt and angular, 



366 



CURVATURES OF THE SPINE. 



Fig. 116. 




is gradual, resembling a segment of a circle. There is angular projec- 
tion posteriorly of the spinous 
processes, and the spine is bent 
forwards in consequence of de- 
struction of the bodies of the 
vertebrae which support the super- 
incumbent weight. 

As the disease advances, the 
patient usually loses all sensa- 
tion and motion in the parts be- 
low the point of pressure on the 
spinal cord ; in short, he becomes 
affected with a paraplegia ; the 
power of motion being generally 
first lost, and last restored, as 
explained in describing the state 
of the parts. The patient loses 
control over the bladder and the 
sphincter of the rectum, so that 
the urine and faeces pass off invo- 
luntarily ; or if the pressure on 
the cord be very great, there may 
be complete retention of the urine. 
Slight difficulty of passing urine has often been found to be an early 
symptom. The easy .performance of the functions of the digestive and 
respiratory organs is more or less interrupted ; the bowels are generally 
constipated ; and the patient complains of a sense of fulness and tight- 
ness at his stomach, and in many cases of pain. These conditions of 
the organs of digestion and respiration are supposed to be produced 
through the connexion between the spinal and ganglionic nerves ; and 
this supposition is probably correct ; but there can be no doubt that the 
function of respiration is often rendered difficult in curvature in some 
situations by pressure on the intercostal nerves, which are thereby 
rendered incapable of calling into action the intercostal muscles over 
which they preside, to assist in enlarging the chest in inspiration. To 
this point we shall afterwards have occasion to refer. In the progress 
of the disease abscess may appear, the situation where it shows itself 
varying, as formerly stated, according to the situation of the disease ; 
its appearance is usually attended with increased derangement of the 
general health, and under the continuance of the discharge and irrita- 
tion, hectic fever to a very urgent extent supervenes, and the bowels or 
some other internal organs becoming infected, death ensues. Such are 
in general the symptoms of angular curvature, but they differ conside- 
rably in different cases, particularly as to the local symptoms, which in 
some instances are as above described, while in others there is no pain 
or tenderness — the only local symptom being the deformity. If the 
deformity depend on mere absorption, there may be no pain, but it is 
an important fact which should always be kept in view, that scrofulous 



Fig. 116. From a patient. 



CURVATURES OF THE SPINE. 367 

caries of the spine, as is mentioned by some authors, and as I have seve- 
ral times found, may run its course, and yet the patient may not expe- 
rience any pain or any local symptom beyond a sense of weakness and 
weariness of the affected part. So little pain is there, that in many in- 
stances the curve has been formed before the real seat of the disease has 
been suspected. In scrofulous caries there is generally less pain than 
when the disease originates in destruction of the cartilages ; but suppu- 
ration usually takes place earlier. These differences, the history of the 
case, and the presence or absence of a scrofulous diathesis, may assist us 
in forming some opinion ; but we have no sure guide enabling us in the 
living body to arrive at a certain knowledge, whether the disease has 
originated in scrofulous caries of bones, or in destruction of interverte- 
bral cartilages. The symptoms of curvature vary also according to the 
part of the spine affected. When it occurs in the lumbar region, and 
more especially towards its lower part, it is not usual, unless the disease 
be to a great extent, to find the altered sensations and spasmodic 
twitches in the early stage, or the paraplegia in the latter, as the great 
size and the form of the bodies render the contents of the canal less 
liable to pressure. When the curvature is in the dorsal region, the pro- 
jection, owing to the great length of the spinous processes, becomes very 
marked, and the chest considerably altered in shape, being flattened 
laterally, the ribs projecting backwards, following the vertebrae with 
which they are connected, and the sternum appearing too far forwards. 
There is at times palpitation, and in some instances difficulty in breath- 
ing, occasioned by compression of the intercostal nerves, or of the spinal 
cord above their origins ; but this symptom is not so frequent when the 
curvature is in the dorsal, as when it is in the cervical region. W T hen 
it is in the cervical region, the head is bent forwards, the prominences 
behind are not large, unless the seventh cervical vertebra be involved, 
and the respiration is difficult. In the early stage, there may be pains 
and twitches of the muscles of the upper extremities as well as of other 
parts inferior to the seat of the disease. Sometimes when the disease 
is in the cervical region, especially in its upper part, it proves fatal by 
producing effusion in the brain, and in some cases the odontoid process 
having lost, in the progress of the disease, the attachments of the liga- 
ments which keep it in its proper situation, presses on the spinal cord, 
and thereby causes immediate death, the seat of the pressure being 
higher up than the origins either of the phrenic or of the intercostal 
nerves which preside over the actions of the muscles of respiration. 
Having thus given a short account of the symptoms of angular curvature 
of the spine generally, and the additional symptoms peculiar to curva- 
tures in particular situations, we shall next refer very briefly to the 
treatment. 

Treatment. — Any attempt to remove the curvature would be most 
injudicious. Anchylosis is the only favourable termination to be hoped 
for, and therefore the object aimed at in treatment should be, to place 
the patient under the circumstances most likely to conduce to that 
result. With that view, it is indispensable, first, to keep the patient in 
a recumbent position, so as to remove from the diseased parts the 
pressure of the superimposed weight, and to preserve the parts as much 



368 CURVATURES OF THE SPINE. 

as possible in a state of perfect quietude in that position ; and secondly, 
to use all means, judicious and available in the circumstances of the case, 
for maintaining the general health. In some cases local remedies are 
highly beneficial. 

That it is necessary to confine the patient to the recumbent position, 
does not admit of question, for it is evident that the superimposed 
weight pressing on the diseased part, must not only act as a source of 
irritation, but must also tend to increase the curvature ; and it can 
only be effectually removed by placing the body in the horizontal posi- 
tion. And that any effort which nature may make to effect anchylosis 
may not be defeated, it is further necessary that the parts should, as 
much as possible, be prevented from being moved upon each other. 
Another advantage which results from preserving the parts at perfect 
rest in the horizontal position is, that the removal of the irritation, 
Caused by the superincumbent weight, from the diseased parts, diminishes 
the danger of the formation of abscess, which (as formerly stated) is a 
most unpromising occurrence, and must induce the gloomiest appre- 
hensions as to the ultimate results. One of the best means for ful- 
filling the above indications is, to place the patient in the supine posi- 
tion on Earle's bed, which, besides other advantages, rendering it very 
convenient for this part of the treatment, allows the relative position of 
the trunk and limbs with regard to each other to be slightly changed, 
without any risk of moving the diseased parts on each other. The 
slight change thus allowed renders the confinement to the recumbent 
position much less irksome than otherwise it would be. As an addi- 
tional precaution for preserving the diseased parts from any movement 
it is in many instances advisable to apply splints on each side of the 
spine. The splints in such cases must suit the shape of the parts to 
which they are applied. Some recommend the patient to be placed in 
the supine posture, but others give the preference to the prone position, 
because in that attitude the superimposed weight is more effectually re- 
moved, — there is no risk of heat and irritation from pressure, — it favours 
the return of venous blood from the bodies of the vertebrae, — and the 
approach of paralysis, it is thought, may be deferred, as matter will 
gravitate away from the medulla. This position is also very convenient 
when local applications are necessary, and in some cases the curve is so 
abrupt, that it is almost impossible with every precaution to keep the 
patient long on his back without producing irritation of the soft parts. 
But notwithstanding the above-mentioned advantages, I confess I have, 
in the majority of cases, found treatment conducted in the supine posture 
more satisfactory, and chiefly, I believe, from the diseased parts being 
more easily preserved in a state approaching to complete immunity 
from motion, than is possible when the treatment is conducted with 
the patient in the prone position, in which I have often been annoyed 
by finding it impossible to prevent the patient from moving the upper 
part of the spine by frequently moving the head and shoulders ; and as 
far as my experience goes, the supine position is preferred by patients. 
Rest, however, of the diseased parts, and the recumbent position, 
whether the body be prone or supine, are of the utmost importance 
from the very commencement of the disease, until a cure is effected by 



CURVATURES OF THE SPINE. 369 

anchylosis. When it is believed that anchylosis has taken place, and 
the patient is allowed to resume the erect attitude, it is a judicious pre- 
caution to employ for some time an apparatus, such as that generally 
known by the name of the spine supporter, for removing the superin- 
cumbent weight. 

The maintenance of the general health is another and equally im- 
portant indication, but unfortunately some of the best means for ful- 
filling it are not compatible with the rest and the recumbent position 
which form essential parts of judicious treatment. The great importance 
of attending to the general health must be evident, when it is considered 
under what circumstances scrofulous deposits are -most apt to take place 
in bone. In individuals of a scrofulous diathesis, insufficient nutriment 
or clothing, living in a damp and cold or impure atmosphere, want of expo- 
sure to the sun's rays, mental depression, and any cause of debility acting 
permanently or habitually for a length of time, have unquestionably an 
influence in exciting scrofulous deposits in bone, as well as in other 
textures. These considerations suggest the necessity, especially in 
scrofulous cases, of a generous digestible diet, living in a pure dry 
atmosphere (the bracing air of the seaside being often highly beneficial), 
exposure to the light of the sun, the cultivation of habitual cheerfulness, 
the proper regulation of the digestive apparatus, and the use of such 
remedies as from the particular circumstances of the case are best cal- 
culated to improve the general health. The tonic medicines generally 
found most useful are the preparations of iron. But as far as medicine 
is concerned, I believe the most important point is, to have recourse 
to those remedies which, from the particular circumstances of the 
case, seem most likely to preserve the digestive organs in a proper 
state. Besides these means, in some cases, local remedies are neces- 
sary ; but the employment of them will depend on the nature of the 
cause of the disease. If the disease depend upon scrofulous caries 
of the vertebrae, or upon softening with absorption without ulceration 
or caries, depletion would be worse than useless, and would tend to 
weaken the patient. In these cases, the surgeon must content himself 
with advising the recumbent position, maintaining the diseased parts in 
a state of quietude, and prescribing all suitable means for preserving 
the general health. In scrofulous caries, benefit will often be found 
to accrue from the early and very cautious employment of counter-irri- 
tation, along with the treatment here alluded to. If the curve arise 
from inflammation of the bodies of the vertebrae, of their investing mem- 
brane, or of the intervertebral cartilages, slight local depletion by leeching 
or cupping at the commencement of the disease, and afterwards counter- 
irritation, are known to be highly beneficial. The repeated application 
of small pieces of blister to each side of the vertebral column at the seat 
of the disease has been found well suited for children, and caustic issues 
for adults. Of the various means for producing counter-irritation, 
Mr. Pott gave the preference to caustic issues. I have used them very 
frequently, and in some instances with gratifying results. It is im- 
proper to produce a great discharge, which would tend to weaken the 
patient, and besides, the long continuance of a profuse discharge and of 
irritation might induce hectic fever. If abscesses form, the issues 

24 



370 CURVATURES OF THE SPINE. 

should be discontinued. Mr. Pott, whose valuable works contain many 
cases of disease of the spine, attended with paralysis, successfully 
treated by the application of counter-irritants, was the first who pointed 
out to the profession the results of such practice, and many have since 
followed it with equal success. About two years ago I ceased to attend 
a patient, in whose case I was much gratified with the result of using 
caustic issues, together with rest and the recumbent posture ; and I 
refer to the case as a striking example of the complete restoration of 
sensation and the power of motion of the lower limbs, after they had been 
for eighteen months considerably affected, and for eleven months en- 
tirely lost. 

The patient, who was thirty years of age, had suffered for a conside- 
rable time from pain and a sense of weakness in his back ; he afterwards 
became affected with angular curvature in the middle of the dorsal re- 
gion, and after the usual train of symptoms, ultimately lost all sensation 
and power of moving the limbs. The power of motion was first lost, 
and sensation was first restored ; but the loss of both sensation and 
motion was as complete as possible. When I first saw him, he had 
lost the use of his limbs for several months, and the curve was rather 
abrupt, and involved three of the dorsal vertebrae. After treatment 
had been employed for four months, the sensibility of the limbs began 
to return, and ultimately it became perfectly natural, and this was fol- 
lowed by a restoration of the power of motion ; and for two years the 
patient has been in every respect perfectly well, without any re- 
mains of the disease except the curve. I am satisfied that anchylosis 
has taken place. The case is interesting, as affording a remarkable 
confirmation of the fact, that the functions of the spinal cord may be 
for a long period completely suspended, and yet afterwards perfectly 
restored. 

Some have gone so far as to affirm, that issues and counter-irritants 
are of no use whatever in this disease ; an assertion which can only be 
explained by the want of success consequent on their injudicious adop- 
tion. 

POSTERIOR CURVATURE, OR EXCURVATION. 

This distortion may be the consequence of scrofula, rickets, or mol- 
lities ossium, or of common or specific inflammation affecting the spine, 
beginning sometimes in the bodies of the vertebrae, sometimes in the 
intervertebral substances ; or it may arise from a softened condition of 
the spine, or from debility consequent on mesenteric disease, or from 
weakness of the muscular system, however induced, or from constantly 
or frequently keeping the spine in an improper attitude, as is the case 
with studious persons, who contract a habit of leaning over books, or 
with clerks who have not been careful to avoid stooping while writing, 
or with individuals belonging to certain trades, as printers, or watch- 
makers ; or it may be, as is often observed in girls, a consequence of a 
careless manner of allowing the shoulders and arms to hang forward. 
But whatever may be the primary exciting cause, the curvature will in 
almost every instance depend, 



CURVATURES OF THE SPINE. 



371 



1st. On general caries of the anterior surfaces of the bodies of many 
vertebrae, the result of either common or specific inflammation ; or, 

2d. On compression of the bodies of the vertebrae from softening ; 
or, 

3d. On weakness of the muscles that support the spine ; or, 

4th. On combinations of some of the preceding conditions. 

Symptoms. — Either a part or the whole of the spine may be affected. 
There is an unnatural rounded 
prominence on the back, the 
distinguishing peculiarity of 
which is the absence of that 
abruptness which is found in 
angular curvature. If the curve 
be situated in the cervical re- 
gion, the chin falls towards the 
sternum, producing what is 
commonly called " the stoop." 
When the whole spine ft af- 
fected, forming a semicircular 
curve forwards, the patient, 
when sitting, is disposed to 
support his trunk, if the dis- 
ease be not far advanced, by 
placing his hands upon his 
knees, and, if it have made con- 
siderable progress, by placing 
his elbows upon his knees; and 
when walking, he has an in- 
clination to rest his hands on 
anything which he may be 
passing, to enable him to bear up under the superincumbent weight, 
which becomes very overpowering. The local and general symptoms 
vary according to the state of the spine on which the curvature depends, 
and the condition of the body in which it takes place. From the gradual 
form of the curve, the functions of the cord are not interrupted. 

Treatment. — In considering what kind of treatment is proper, the 
surgeon must be guided by the nature of the cause of the disease. If 
the distortion depend on general caries, then the same treatment as in 
angular curvature is suitable. If it occur as an effect of rickets, or 
syphilis, a most important part of the treatment consists in the employ- 
ment of the remedies adapted for these constitutional diseases. When 
it arises either from a softened condition of the vertebral column itself, 
or from weakness of the muscles necessary for maintaining it in the 
erect position, the surgeon should endeavour, by strict attention to the 
general health of the patient, to invigorate his frame. To effect this, 
pure air — a saline atmosphere, especially in scrofulous individuals, is 
often beneficial — generous diet, wine, or any other stimulus that agrees 
with the patient, tonics, of which the preparations of iron will, in many 




Fig. 117. Excurvation of spine. From Tuson. 



372 . CURVATURES OF THE SPINE. 

cases, be found among the most useful, and sea-bathing, should be en- 
joined. If sea-bathing be inconvenient, salt ablutions, or sponging the 
body with salt water, may be substituted for it. The regular and daily 
use of friction by means of the hair-glove or flesh-brush, and exercise 
on foot, should also be adopted. The patient should never take so much 
exercise as to induce weariness, and he should afterwards assume the 
recumbent position, until he experiences an aptness or fitness for further 
exercise. The surgeon should also recommend friction, with some 
stimulating embrocation, all along the spine, and such amusements as 
tend to strengthen the muscles of the back. " When a case of stooping 
is confirmed," Mr. Stafford remarks, " a regular course of the gymnastic 
exercise is perhaps the best treatment that can be pursued. These, 
however, must be employed with great caution, as by their too violent 
use in the first instance, much mischief may arise. In simple cases, 
very simple means may be resorted to. One plan I am inclined to 
think would be attended by the greatest success, and which is, a weight 
being suspended from the shoulders and resting on the abdomen. My 
reason for thinking this is, from having obserVed in a regiment of sol- 
diers that the one who carries the great drum is invariably the straight- 
est man. For the reason just mentioned, it would be a good plan to 
make children play at soldiers, and let the one who is disposed to stoop 
carry the drum in the same manner as the drummer of a regiment. I 
have little hesitation in saying the habit would soon be cured. Another 
very good exercise, also, would be to make the individual play at cym- 
bals ; he would be forced to extend his arms in the air and look up- 
wards, by which the head and trunk would be thrown backwards, whilst 
the muscles of the shoulders would be in constant action." 

Mr. Stafford farther says : — " The use of the dumb bells would be found 
in some cases of great service ; for instance, where the shoulders hang 
forward, by which the chest is narrowed, and the sternum is forced in by 
the clavicles; by their employment the shoulders would be thrown back- 
wards, and the chest expanded. Other methods no doubt might be ad- 
vised ; as a general rule, however, any exercise which will bring the 
muscles of the back into action will be of great utility in this description 
of distortion." 

In curvature depending upon caries of the spine nothing could be 
worse than these amusements ; hence the importance of diagnosis. When 
the curvature arises from bad habits, as constantly leaning forward, 
allowing the shoulders and arms to hang forward, or from an employ- 
ment in which the spine is bent forward, the habit must be corrected, 
and the employment which produced the curvature must for a time be 
discontinued. In this variety of curvature, mechanical support com- 
bined with a certain amount of exertion is sometimes useful. Large 
padded splints are by some applied to the sides of the abdomen, and 
secured by flannel bandages. Others employ a wooden shield, the con- 
cavity of which they apply to the convexity of the patient's back ; gra- 
dually diminishing the concavity by placing in it another layer of flannel 
or some soft padding. These appliances should not be worn constantly, 
but for a short time each day. In the few cases where mechanical sup- 
port during a part of the day is advisable, it may be given by more 



CURVATURES B» THE SPINE. 373 

elegant appliances than those referred to above ; appliances which can- 
not confine the parts or induce injurious pressure in any way. 

ANTERIOR CURVATURE, OR INCURVATION. 

This, which happily is the rarest of all the curvatures of the spine, is 
remarkable for the rapidity with which it proceeds, when it has once 
commenced. It may happen as the consequence of rickets, mollities 
ossium, common or scrofulous inflammation beginning in the spine, and 
primarily affecting either its bones or softer textures ; or, it may arise 
from a softened condition of the vertebral column, or from any state 
which so deranges the due balance in the action of the muscles main- 
taining the spine in its proper attitude, as to render the extensor muscles 
of the vertebral column too powerful for their antagonists. 

The treatment consists in the application of the principles already 
laid down for the treatment of these particular conditions. 

LATERAL CURVATURE. 

This is by far the most common of all the curvatures of the spine, 
and is more frequently met with in girls than in boys, and in the chil- 
dren of the wealthy than in those of the poor, and much more frequently 
in the females of this climate than in those who live in warmer latitudes. 
It seldom commences after the age of puberty, except when induced by 
the excessive action of the muscles of one side. That girls, are more 
liable to it than boys is, no doubt, owing to the serious defects in their 
physical education. The injudicious means adopted for improving the 
figure by preventing the proper play of the muscles of the trunk, by 
retarding the development of the bones and muscles, and by producing 
more or less absorption of them by compression, cannot but be highly 
injurious ; and to these causes, aided by the want of proper exercise, 
and of sufficient exposure to the open air, is to be referred the frequency 
of this disease in girls, — causes which more frequently affect the wealthy 
than the middle and lower classes. The comparative rarity of lateral 
curvature as a primary form of disease among the poor, is proved by 
general experience, and by the statistical fact, that of thirty-two thou- 
sand nine hundred and ninety-one patients who presented themselves 
for relief at Middlesex Hospital in five years, there were not more than 
twenty affected with lateral curvature as a primary disease. As a 
secondary result arising from other affections, such as disease of the hip, 
or disease of the knee, lateral curvature is frequently found among the 
poorer classes. It seems to be the want of attention to this distinction 
which has induced some to question the fact of the comparatively rare 
occurrence of lateral curvature among the poor. The comparative ex- 
emption from this disease in the females of warm climates has been 
attributed to the loose clothing they are obliged to wear, allowing the 
due development of their various organs, to the want of stays, and of 
many injurious restraints, and to their not being subjected to the 
fatiguing confinement to an irksome position, as the young ladies of this 
country often are daily for many hours together, in acquiring a variety 
of accomplishments. 

Causes. — The principal predisposing causes are rickets, mesenteric 
disease, a softened condition of the bones of the spine, compression of 



374 CURVATURE* OF THE SPINE. 

the thorax from tight lacing, weakness, especially when consequent on 
measles, hooping-cough, or other infantile diseases, want of proper exer- 
cise and exposure in the open air, and any circumstance which acts 
unfavourably on the general system before the various organs have 
attained their full development. Tight lacing is not uncommonly a 
predisposing cause of distortion of the spiDe. This custom, restraining 
the actions of the muscles, prevents their natural development, so that 
they become attenuated; the bones also to a certain extent become 
diminished by absorption, and softened, so as to be unable to sustain 
the weight they were destined to support ; and the cavity of the thorax 
is diminished, in consequence of which there is not sufficient room for 
the healthy and easy performance of the functions of the heart and 
lungs. 

The immediate exciting causes are, the habit of standing on one leg, 
standing, sitting, or reclining in a position in which the spine is inclined 
too much to one side, injudicious confinement of a young person for a 
long time to one position without support to the back, the consequent 
weariness and irksomeness obliging the child to lean to one side to 
obtain relief, the disproportioned use of the muscles of one side, as in the 
case of persons engaged in certain avocations, or of children to obtain 
relief from the uneasy sensations caused by ill-made clothes, and lying 
on a soft bed with a very high pillow. These are the principal exciting 
causes of. lateral curvature, and the rationale of their operation is suffi- 
ciently obvious. 

When the distortion arises from the habit of standing on one leg, the 
first deviation from the proper shape of the spinal column takes place 
in the lumbar region, constituting what is termed the primary curve; 
and this will be followed by a curve in the dorsal region ; which, to dis- 
tinguish it from the former, is called the consecutive curve. If the con- 
vexity of the curve in the lumbar region be to the left side, that of the 
dorsal region will be to the right : so that if the distortion be to a great 
extent, the shape of the spine will somewhat resemble that of the letter 
S reversed : thus giving rise to the appearance of " growing out" of the 
right shoulder and left hip ; but if the convexity of the curvature in the 
lumbar region be to the left, and the shape of the spine will more or 
less resemble the letter S, according to the extent of the contortion. 
The consecutive curve is the result of an effort to maintain the upright 
position ; or, in other words, when a primary curve is formed in the 
lumbar region, the muscles on the opposite side of its convexity, and 
higher up, draw the spine in the contrary direction, and the one curva- 
ture compensating in a measure for the other, allows the centre of 
gravity still to fall upon the pelvis. The primary curve is always the 
bolder, and the consecutive curve may occupy the dorsal, and a consi- 
derable part of the cervical region ; or there may be two consecutive 
curves in opposite directions, one in the dorsal and the other in the 
cervical region. 

The same explanation may be given of the operation of several other 
exciting causes, such as the bad habit of standing, sitting, or reclining 
in an awkward attitude, or of leaning to one side to obtain relief from 
the weariness and aching sensations caused by too long confinement to 
one position. The disproportioned use of the muscles of one side is well 



CURVATURES OF THE SPINE. 



known to be an exciting cause of curvature. Examples are occasionally 
met with in blacksmiths, dragoons, and in persons engaged in peculiar 
avocations, in whom the muscles on one side, from being frequently 
called into action, become so strong and so fully developed, as to over- 
power those of the opposite side, and draw the spine out of the perpen- 
dicular. Mr. Child records the case of a printer's apprentice, who was 
in the habit of frequently pulling the press with his right arm, and this 
gave rise to a curvature in the dorsal region with the convexity to the 
right side ; the rhomboidei and trapezius muscles being tense, rigid, and 
prominent. In such cases the primary curve will be in the dorsal 
region, and will soon be followed by a consecutive curve in the reverse 
direction in the lumbar region. The improper use of the muscles of 
one shoulder is sometimes a cause of curvature in females. Mr. Staf- 
ford remarks, " A girl shall have ill-made clothes ; for instance, one of 
the shoulder-straps will be constantly slipping off the shoulder ; she, of 
course, will endeavour to replace it ; by this effort she is obliged to 
elevate the shoulder, and thus she not only brings into action the 
muscles of that side, but at the same time inclines the spine to the one 
that is opposite. The effect of this position must be obvious, for on the 
one hand she increases the power of the muscles on one side, which 
assist in pulling the spine out of the perpendicular ; and on the other, 
the centre of gravity is destroyed." The above are the principal 
exciting causes, which acting separately, or two or more of them in 
combination, give rise to lateral curvature ; but in some instances the 
spine becomes distorted without any known exciting cause. Sometimes, 
although rarely, lateral curvature is found to depend on caries : in such 
a case, whatever excites inflammation about the spine may be an exciting 
cause of the distortion. I have in my own col- 
lection a good example of this condition, in which 
the primary curve is in the lumbar region, and 
is caused by caries of lumbar vertebrae. The 
possibility of this form of distortion depending 
on caries, suggests the necessity of great caution 
in forming our diagnosis. In such cases the 
curve will be more abrupt in its form, and more 
rapid in its progress than in the other varieties 
of lateral curvature. 

Symptoms. — The spine exhibits unnatural, but 
seldom abrupt, deviations from the mesial plane. 
These are accompanied, more or less, with a 
sense of weakness and weariness, which, in some 
instances, increases especially towards night, and 
after exercise so greatly as to become even pain- 
ful, and to produce a desire to lie down in 
order to relieve the spine from the superincum- 
bent weight. If the distortion depend on caries 
(which is exceedingly rare), there may be actual 
pain ; but this state sometimes exists, as has 
been already stated, without the patient being 



Fiff. 118. 




Fig 118. From a patient. 



376 



CURVATURES OF THE SPINE. 



sensible of any pain. The local appearances vary according to the ex- 
tent, direction, situation, and number of the curvatures. If there be 
two curvatures, the one in the lumbar region, with its convexity to the 
left side, and the other in the dorsal, with its convexity to the right, 
there will be a falling-in of the right loin, a fulness in the corresponding 
part on the left side, and an appearance of projection and elevation of 
the hip ; an alteration, also; in the form of the chest, which will be elon- 
gated, prominent, and round on the right side, and shortened and flat- 
tened on the left ; the right shoulder will be elevated and project out- 
wards, and the right mamma will be prominent ; the left shoulder will 
fall down, and the mamma, from the flattened state of the thorax, appear 
smaller than on the right side. The rationale of these symptoms will be 
obvious, when the effects of lateral curvature upon the thorax are explained. 
Two of the most striking symptoms are the "growing out," as it has been 
called, of the right shoulder, and the prominent and elevated appearance 
of the hip. The extent of the above symptoms will correspond with the 
boldness of the curvature. When the convexity of the lumbar cuire is to 
the right side, and that of the dorsal to the left, the appearances which in 
the former case were observed on the right will be found on the left 
side, and vice versd. The above are the symptoms of lateral curvature, 
when there are only two curves, and these situated as described, and 
not of a very great extent. In an advanced stage, however, of this dis- 
ease, an alteration is observed in the symptoms ; the breast, like the 
scapula, does not remain prominent on the convex side of the dorsal 

curvature, but falls backwards, in consequence 
of the ribs in front losing their convexity and 
becoming flattened as the disease makes pro- 
gress. If, however, there be three curvatures, 
and if a few of the superior dorsal vertebrae 
be, together with the cervical, involved in the 
uppermost curve, and if the distortion be 
considerable, the appearance will be different. 
Besides the symptoms already mentioned in 
the lumbar region, and the projection back- 
wards of the scapula on the convexity of the 
dorsal curvature, there will be flatness of the 
chest and falling-in of the neck on that side, 
together with fulness of the neck and breast, 
and elevation of the shoulder of the opposite 
side. In this variety the scapula projects 
backwards at its lower, and falls forwards at 
its upper part, on the convex side of the dorsal 
curve ; but it is not raised so much upwards as 
on the opposite side. The appearance is pe- 
culiar, from the projection backwards of the 
shoulder and the falling in of the mamma on 
the one side, and the rising up of the shoulder, 
and the prominence of the mamma on the other. The convexity of the 
uppermost curve produces the fulness on the one side of the neck, and 

Fig. 119. From a patient in my wards in the Royal Infirmary. 



Fig. 119. 




CURVATURES OF THE SPINE. 



377 



the explanation of the other peculiar symptoms is, that, on the side on 
which the mamma is prominent and the shoulder raised up, the superior 
ribs are supported by the convexity of the uppermost curve, whereas 
those on the opposite side are connected with the concavity, and, there- 
fore, fall in. 

EFFECTS OF LATERAL CURVATURE ON THE SPINE AND ON THE TRUNK. 

With reference to the vertebral column, it is observed that the effect 
of the curvature on the convex side is to separate the transverse pro- 
cesses from one another, to incline the spinous processes outwards, and 
to enlarge the bodies of the vertebrae and the intervertebral substances, 
so that they have the appearance of being expanded. On the concave 
side the reverse prevails ; the transverse processes are brought too near 
each other, the spinous processes curve inwards, and the bodies of the 
vertebrse and the intervertebral cartilages are diminished in depth by 
interstitial absorption. The height of the column is diminished, and if 
the distortion be considerable, there is rotation of the spine to the same 
side as the curvature. The muscles which run along the convex side 



Fig. 120. 



Fig. 121. 




are inordinately stretched, and consequently weakened ; while those on 
the concave side are preternaturally contracted and rigid. These alte- 

Fig. 120. Front view of lateral curvature of spine. From a preparation in ray 
museum. 

Fig. 121. Back view of same preparation. 



378 CURVATURES OF THE SPINE. 

rations are not only to be discovered on dissection, but in the living 
body also. The surgeon can satisfy himself of the existence of these 
alterations both before and after dissection. If the curve originate in 
the use of one shoulder more than the other, the muscles extending 
from its convexity to the scapula will be preternaturally tense and 
large, when compared with those of the opposite side. There will be, 
on the concave side of the curve, flattening and shortening of the thorax, 
with diminution of the intercostal spaces ; while on the other side, the 
thorax will be elongated and rounded in form, and the intercostal spaces 
enlarged, in consequence of the ribs being removed farther from each 
other. The condition of the ribs explains the symptoms observable 
about the shoulders and mamm^. The transverse measurement of the 
thorax is diminished, and, in consequence, the sternum usually becomes 
preternaturally prominent : and, in many instances, the diminished 
capacity and changed form of the cavity of the chest interfere with the 
easy play of the heart and lungs, and thus occasion to the patient 
annoying sensations within the chest. 

Treatment. — The treatment of this affection, when dependent on 
rickets or caries, consists in the application of the principles laid down 
for the treatment of those particular diseases. If the curvatures arise 
from the operation of other causes, and are neither of great extent nor 
of long standing, they may, by judicious management, be completely 
removed: in this case, the treatment may be "termed curative. But 
when the deviation of the vertebral column is to a great extent, and the 
bones have acquired their consolidated state, the unnatural configura- 
tion of the bony structure cannot be removed ; and all the surgeon can 
then do is, to employ remedies calculated to prevent the progress of the 
deformity. Here the treatment may be denominated palliative. When 
the deformity is caused by the disproportioned action of the muscles of 
one side, their action must be discontinued, and the muscles of the oppo- 
site side brought into exercise. 

If the curvature has arisen from standing on one leg, or from any of 
the various improprieties of attitude already referred to, an essential 
part of the treatment is the discontinuance of the bad habit ; for so long 
as the exciting cause is allowed to remain in operation, no treatment 
will be of any avail. Another great object will be, to call into use those 
muscles whose action will tend to bring the spine into its proper posi- 
tion : these will, of course, be the muscles attached to the concavity of 
the curvature. This may be done in various ways, by the use of the 
dumb-bell, turning the wheel, or by such gymnastic exercises as tend to 
bring into play the muscles of the trunk, — those especially whose con- 
tractions are calculated to draw the spine to the erect attitude. In the 
case of children, a simple and excellent plan is, to induce them to play 
at such games as will call into exercise those muscles by which the ver- 
tebral column may be restored to its normal form ; thus, if the curva- 
ture has arisen from standing on one leg, Mr. Stafford suggests, that a 
good way of bringing into action the muscles of the opposite side would 
be the favourite game of hop-scotch; and when it has been caused by 
the disproportioned use of the muscles of one shoulder, as in cases of 
raising up the shoulder to obtain relief from the annoyance of the shoul- 



CURVATURES OF THE SPINE. 379 

der-strap falling clown, lie advises that the game of battledore and 
shuttlecock be played with the opposite hand. When the disease has 
not made great progress, and the bones have not become stiff by anchy- 
losis, or - by great interstitial absorption on the concavity, and growth and 
expansion on the convexity, of the curve, the means above mentioned 
will generally be found sufficient to restore the spine to its normal 
form. 

When the disease has arisen from general debility, however induced, 
which has rendered the spine too weak to support the superincumbent 
weight, the treatment will consist in the use of means calculated to 
strengthen the general system, and in certain local measures directed 
to the state of the spine. Some of the most important measures for the 
purpose of invigorating the system are, the adopting of a generous diet, 
living in a pure and bracing atmosphere, the use of wine, provided it 
agree with the patient, the due regulation of the bowels, and the em- 
ployment of whatever medicinal tonic seems most indicated by the par- 
ticular situation of the patient. To maintain the right performance of 
the functions of the digestive organs, and to preserve the bowels in a 
state neither relaxed nor constipated, are often the only occasions for the 
employment of medicine internally. Sea-bathing at the proper season 
is often advantageous ; but if this be inconvenient, recourse may be had 
to salt ablutions, or sponging the body with salt-water. In addition to 
these, the regular and daily use of friction by means of the hair-glove or 
flesh-brush, and exercise on foot should be employed, care, however, 
being taken that the exercise be not to such an extent as to induce 
weariness. After exercise the patient should rest in a recumbent posi- 
tion until she experience a fitness for further exertion. To keep patients 
always in that position would be extremely injudicious, as the debility 
thereby induced would predispose more strongly to the disease ; but to 
recline on a couch or sofa for three or four hours altogether in the course 
of the day, not at once but at different periods, with intervals of gentle 
exercise or amusement, would relieve the weak part from the superin- 
cumbent weight, and thus be not only agreeable to the feelings of the 
patient, but also calculated to be useful. Together with this treatment 
certain local measures are beneficial, such as friction along the spine with 
some stimulating embrocation, especially along the muscles which chiefly 
require to be stimulated. Exercising the muscles of the trunk with the 
body in the horizontal position, if conducted with judgment and care, is 
also often highly beneficial ; the exertion of muscular action, while the 
spine is free from the pressure of the superincumbent weight, tends to 
restore it to its normal position. Such exercises, by calling into play 
the muscles extending between the ribs and the arm, are also particu- 
larly well adapted to correct the deformity of the thorax. The appa- 
ratus employed by Mr. Shaw, and the couch with the exercising frame 
recommended by Mr. Tuson (a modification of which, in a greatly sim- 
plified form, I have employed for exercising the muscles while the body 
is in the recumbent position) are well adapted for the purpose ; but all 
that is required can easily be fixed to the extremity of a couch. It is 
unnecessary to describe the different pieces of apparatus above referred 



380 CURVATURES OF THE SPINE. 

to, for if the principle is to be adopted of exercising the muscles with 
the body in the recumbent position, there can be no difficulty in con- 
triving mechanism for its practical application. Such branches of a 
girl's education as require sedentary attention, much mental exertion, 
or long confinement to the sitting position, must be suspended. Tight 
lacing and all mechanical supports, which tend to retard the develop- 
ment, or prevent the exercise of the various organs, or induce the 
patient to lean to them for support instead of endeavouring to maintain 
a proper attitude by the action of her own muscles, are positively inju- 
rious ; but still, if the patient be unequal to the necessary exercise, some 
support during part of the time she is in the erect attitude, will be found 
beneficial. Some of the spine-supporters, which sustain the superincum- 
bent weight, or rather transmit it to the pelvis without exerting pressure, 
are best adapted for this purpose. 

Of late years recourse has been had, for the cure of lateral curvature, 
to the operation of dividing certain muscles of the spine. This is in 
some respects analogous in principle to the operation of dividing the 
sterno-mastoid muscle for the cure of some forms of wry-neck, or of 
dividing certain muscles for the cure of club-foot ; although certainly 
we have no reason to expect it to be so generally useful as those opera- 
tions. When the distortion proceeds from disease of the bones, or from 
any constitutional disease, or from general debility, an operation would 
be most unjustifiable ; and I think it will be evident from what has been 
stated regarding the causes of lateral curvature that the cases must be 
exceedingly few, in which there is a reasonable prospect of an operation 
proving advantageous. In cases of curvature arising from or attended 
by an excessive exertion of certain muscles, the operation has been per- 
formed with the view of weakening the muscles to whose overaction the 
original production, or the subsequent continuance of the curvature, is 
in part to be attributed. Thus the muscles extending from the con- 
vexity of the dorsal curve to the scapula have been divided, when the 
curvature has been caused by an inordinate action of the muscles of that 
side. In other instances the muscles along the concavity of the curve 
have been divided ; because when a curvature takes place, the muscles 
attached to its extremities and situated along its concavity have their 
extremities brought nearer to each other than is natural, and then con- 
tracting and accommodating themselves to their new position, they not 
only offer an obstacle to the removal of the curvature, but also tend by 
their contractile power to increase it. Mr. Child records a case of a 
printer's apprentice who had curvature in the dorsal region caused by 
pulling the press with his right arm; the rhomboidei and trapezius 
muscles were tense, rigid, and prominent. Mr. Child divided the muscles 
attached to the convexity of the curve, by the overaction of which the 
distortion had been produced ; and the result was favourable. Mr. 
Whitehead of Manchester, has successfully performed the operation of 
dividing the muscles along the concavity of a curvature. The two cases 
are described in the " Medical Gazette," the former in the number of 
Nov. 27th, 1840, and the latter in that of December 4th, 1840. The 
operation of myotomy for the cure of distortion of the spine has been 



CURVATURES OF THE SPINE. 381 

performed by M. Genrin of Paris, Mr. Skey of London, Dr. Hunter of 
Glasgow, and others, with different results ; but as yet the impression 
of surgeons regarding it is decidedly unfavourable. 

MIXED CURVATURE. 

As the various conditions on which curvatures depend, and the prin- 
ciples of treatment suitable to each, have been already explained, it 
appears unnecessary in reference to mixed curvature to say more than 
that the important point is, to ascertain the cause of the curvature, and 
to adapt the treatment accordingly. 



382 



CHAPTER XL 



TALIPES, OR CLUB-FOOT. 



Fig. 122. 



Of this there are four varieties, namely, talipes equinus, talipes varus, 
talipes valgus, and talipes calcaneus. 

Symptoms. — Talipes equinus is the most simple, though not the most 
common, variety of these deformities. It may vary from slight eleva- 
tion of the heel to that position in which the heel is so drawn up, that 
the foot is almost in a straight line with the leg. The weight of the 
body in walking is borne by the anterior part of the foot, and in a pure 
example," equally by all the metatarsal bones; but in some cases where 
the toes incline slightly inwards or outwards, approaching somewhat to 
other forms of talipes, the anterior part of the sole of the foot cannot be 
applied evenly to the ground, and the weight is received chiefly by the 
metatarsal bone of the little or of the great toe, according as the ten- 
dency to lateral displacement is inwards or outwards. The inward 
tendency is the more common, owing, it has been supposed, to the 
circumstance that the natural configuration of the foot admits of more 
extensive adduction than abduction. In many instances, patients, when 

they stand carefully upon the affected foot, 
appear to tread evenly ; but in walking, as 
soon as the foot is placed in the extended 
position, so that the posterior part of the 
astragalus, which is narrow from side to 
side, is received between the two malleoli, 
the foot inclines inwards, and the ball of the 
little toe principally sustains the superin- 
cumbent weight. There is great lateral 
mobility of the foot, especially in the ex- 
tended position. The muscles of the calf 
are contracted, and the tendo Achillis is 
prominent, tense, and unelastic. These con- 
ditions are rendered still more apparent by 
any attempt to bend the foot; and the extent 
to which that can be clone, and the amount 
of resistance offered, vary according to the 
extent of the distortion. The foot is un- 
usually convex above and concave below, and 
in cases of considerable standing, the foot is 
smaller, and the leg, both in length and thickness, less, than on the 
opposite side, showing that the parts are less developed in every way. 




TALIPES. ' 383 

The gait of the patient is peculiar and unpleasing. Pain and a sense of 
weakness are often experienced at the instep from the strain on the 
parts in making exertion ; and walking is often rendered still more dis- 
agreeable to the patient by painful corns forming on the parts on which 
he treads. In many cases the patient can, by a voluntary effort, slightly 
diminish the deformity ; but when the distortion is caused by paralysis 
of the flexors of the ankle, he cannot by a voluntary effort bend the foot 
in any degree; and in such case, if the surgeon place his finger over the 
belly of the tibialis anticus, or of any other muscle in front of the leg, 
and desire the patient to endeavour to excite it to contract, no motion 
whatever will be felt under the finger, — the volition is not followed by 
any change in the muscles, which the patient desires to call into action. 
This method of examination it is desirable to institute, before a 
prognosis be given, as the result of treatment is not likely to prove 
so satisfactory when paralysis is the cause. The above are the symp- 
toms which in a greater or less degree, according to the extent of the 
distortion, characterize this deformity. Talipes equinus congenitus is 
the name given to it when it exists from the period of birth ; and talipes 
equinus acquisitus when it takes place at a subsequent period. 

ABNORMAL CHANGES. 

The bones which present the greatest deviations from their natural 
condition are the astragalus, os scaphoides, and calcaneum, but chiefly 
the astragalus. They are generally somewhat diminished in size, especi- 
ally the astragalus ; and its natural articular facets for the bones of the 
leg are roughened and almost denuded of cartilage, while new ones are 
formed at a greater or less distance backwards according to the degree 
of the deformity ; in the higher grades these surfaces are furnished 
partly by the astragalus, and partly by the calcaneum. The head of 
the astragalus is diminished in size, and its articular surface for the os 
scaphoides is unusually small. The os scaphoides, which is also dimi- 
nished in size but not altered in form, is drawn downwards ; and hence 
the upper part of the head of the astragalus is prominent on the dorsum 
of the foot, and an unusual extent of the upper aspect of the bone pre- 
sents itself, in consequence of the bones of the leg being removed so far 
backwards. The calcaneum is seldom fully developed. In the higher 
grades of talipes it furnishes a facet for the bones of the leg. The 
surface by which it articulates with the os cuboides is contracted in 
extent, and the upper and anterior part of the bone is prominent on the 
dorsum of the foot in consequence of the os cuboides being drawn down- 
wards. The remaining bones of the foot present their natural charac- 
ters, except that they usually show more or less of deficiency in their 
development, and all the bones of the tarsus and metatarsus are so 
arranged, as to give the foot an unusual convexity above, and a corre- 
sponding unusual concavity below. The toes are extended, but Dr. 
Little has given a delineation of a curious specimen belonging to the 
museum of the London Hospital, in which the toes were unusually 
drawn downwards towards the calcaneum, which, Dr. Little remarks, 
was owing to the circumstance that the person to whom it had belonged, 
had not placed the foot upon the ground, but walked upon the knee. 



384 TALIPES. 

The articulating facets of the tibia and fibula are roughened in front and 
denuded of cartilage, from not coming into contact at these parts with 
the astragalus. The above are the abnormal conditions of the bone in 
talipes equinus. That which invariably exists, and is regarded as the 
distinguishing peculiarity, is a greater or less displacement of their 
articulating facets. 

The ligaments in this and the other varieties of talipes are changed, 
being relaxed and shortened so as to correspond with the situation of the 
bones. These alterations are now considered as consequences, not as 
causes of the deformity. At page 45 of his interesting book on Club- 
foot and other analogous deformities, Dr. Little remarks, u The ligaments 
cannot directly influence the production of the deformity ; but its pro- 
gress may be facilitated by their relaxation ; the restoration of the foot 
is impeded by their diminished length, the result of long continuance in 
an improper position." 

The muscles are, in all the varieties of talipes, invariably affected with 
abnormal conditions, which are regarded as the causes of these distor- 
tions. The distinguishing peculiarity is, that the balance between an- 
tagonistic sets of muscles is interrupted. The disturbance of the 
equilibrium of the muscles may arise from complete or partial paralysis 
of the tibialis anticus, or of it and of one or more of the other flexors of 
the foot, and the consequent contraction and structural shortening of 
the muscles at the back of the leg ; or, it may be occasioned by the 
spasmodic contraction ; and, if of long standing, the consequent struc- 
tural shortening of the muscles of the calf, without paralysis of the 
muscles in the front of the leg ; or, it may be unattended by either paraly- 
sis or spasmodic contraction, and be the result (as is often observed 
when the whole voluntary power of the limb is diminished), of the organic 
contraction of the extensors of the foot preponderating over that of the 
flexors. 

The gastrocnemii are the muscles chiefly involved in the production 
and maintenance of this deformity ; and although sometimes other ex- 
tensor muscles are affected, it is comparatively rare that the division of 
any of the tendons, except that of the gastrocnemii, is necessary. 

These are the principal conditions of the muscles which cause genuine 
talipes ; but deformities which in external characters resemble talipes, 
may arise from contraction of the gastrocnemii excited by abscess of the 
leg, or by caries or necrosis of either of the bones of the leg ; from 
cicatrization of extensive ulceration ; or, from the maintenance of the 
foot in a particular position, assumed in consequence of inflammation or 
other painful affections of the joints. In hysterical females, the signs 
of talipes are sometimes exhibited, constituting what has been called 
talipes equinus hystericus ; and in many instances these symptoms have 
been found to subside under the treatment proper for hysteria. In 
cases where dissections have been made, the blood-vessels and nerves 
were found to be, like all the other structures, reduced in size ; but from 
what is stated above, it will be evident, that of all the abnormal condi- 
tions, that of the muscles most chiefly engage the surgeon's attention, 
as to that must be referred the existence of the deformity ; and to the 



TALIPES. 385 

removal, therefore, of that condition, the remedial measures are to be 
directed. 

Treatment. — An improved knowledge of the exciting causes of talipes, 
and of the abnormal conditions of the parts, has led to the adoption of 
sounder and more rational principles of treatment than formerly pre- 
vailed. In all cases of talipes equinus, whether congenital or acquired, 
whether induced by spasmodic contraction of the muscles at the back of 
the leg, or by paralysis of some of those in front, if structural shortening 
has occurred to any considerable extent, the proper treatment consists 
in the division of the tendons of the shortened muscles, and the restora- 
tion of the foot to its proper position by means of mechanical apparatus. 
The nature of the operation and of the mechanical apparatus will be 
presently explained. In cases for which it is suitable, nothing more 
satisfactory can be desired than this method of treatment ; by it I 
treated, with complete success, a case of talipes equinus of thirteen 
years' duration ; and of the many successful cases recorded by Dr. 
Little in his treatise on this subject, the second had, existed for fourteen 
years, the fourth for twenty-nine, and the fifth for thirty-five years, and 
yet the results were perfectly satisfactory. When the structural short- 
ening is to a slight extent, the judicious employment of mechanical 
treatment, without division of tendons, will often prove efficient. In 
each of the two classes of cases, in that which requires the division of 
tendons, and in that which will yield to the judicious application of me- 
chanical treatment alone, the origin of the disease should be minutely 
inquired into ; and if the disturbance of the equilibrium of the muscles 
arise from paralysis of one or more muscles, the state of the central 
parts of the nervous system must be attended to ; or if by the reflex 
and incident functions of the nervous system, it has originated in dis- 
order of the digestive apparatus, or in derangement of other organs, 
treatment must be directed to the removal of the cause, unless it has 
been of so long standing, or of such a nature as to preclude all hope of 
removal. In many cases, where there is no structural shortening, medi- 
cal treatment directed to the origin of the disturbance, whether in the 
nervous system, the digestive apparatus, or in some other organs, will, 
by removing the origin of the disturbance, cure the deformity. In such 
cases an operation is not advisable, but it is prudent, together with 
medical treatment, to employ friction, manipulation, and such mechani- 
cal appliances as will be most likely to prevent structural shortening 
while the spasmodic contraction remains. 

The operation is extremely simple, and may be performed with any 
very narrow sharp-pointed instrument, such as a small, straight, sharp- 
pointed bistoury, or with an extremely narrow knife in the shape of a 
scalpel, or with a narrow-bladed instrument, not more than an eighth of 
an inch in breadth, the cutting edge of which does not extend more than 
five or six-eighths of an inch from the point, the remaining part being 
blunt, so that the instrument can be turned in the wound, and thus the 
operation be effected without so extensive a division of the skin, as 
would probably be occasioned by an instrument with a cutting-edge of 
greater length. It is very important that the wound of the integument 
should be the least possible. In talipes equinus, the tendo Achillis is 

25 



386 



TALIPES. 



usually the only tendon that requires to be divided, but in some 
instances the section of the tibialis posticus and flexor longus pollicis is 
also needful. The division of the tendo Achillis may be effected in the 
following manner : — While the knee is extended and held by one assis- 
tant, and the heel depressed and the toes raised as much as the struc- 
tural shortening will permit by another, for the purpose of rendering 
the tendon prominent and tense, the. surgeon introduces the flat blade 
of the knife at one side (usually the inner side) of the tendon, and 
having passed it under the tendon until the point reaches the opposite 
side, turns the edge backwards, and divides the tendon in withdrawing 
the knife. The division is attended with a grating noise, and its accom- 
plishment is evidenced by the removal of the resistance to the depres- 
sion of the heel, and by the hollow that is left under the integument. 
All experienced orthopaedic surgeons prefer the transverse to the oblique 
section (which some have recommended because a larger surface is 
thereby formed for the effusion of the uniting medium) ; and it may be 
effected, as described above, by carrying the knife before the tendon, 
and cutting from before backwards, or by pinching up the integument 
and sending the knife between it and the tendon with the sides of the 
knife backwards and forwards, and then directing the edge against the 
tendon, and cutting from behind forwards. By either method, the ope- 
ration may be performed in a few seconds ; not more than a drop or 
two of blood escapes, and the external wound is extremely small, being 
not more than the breadth of the instrument, which is carefully with- 
drawn through the opening, by which it w r as introduced. 

A small piece of plaster is placed over the opening, and the foot is 
allowed to remain in its deformed position until the wounds be perfectly 
healed, which is usually not more than two or three days. As regards 

Fig. 123. 




the operation, there is merely a puncture of the skin, and the division 
of the tendon is subcutaneous, so that neither the tendon nor its sheath 

Fig. 123. Stroineyer's apparatus applied. 



TALIPES. 



387 



being exposed, the danger of inflammation is greatly diminished ; and 
that it may be yet further diminished, and the risk of suppuration 
avoided, no means should be taken to restore the foot to its proper 
position, until the wound be perfectly cicatrized. Such is the doctrine 
laid down by Stromeyer, and followed by the most experienced ortho- 
pedic surgeons, as to the period at which extension should be com- 
menced. But M. Bouvier and Mr. Whipple recommend that it be com- 
menced immediately after the section of the tendons. There is also a 
difference of opinion as to the manner in which extension should be 
employed. Stromeyer, Little following his example, and most others, 
bring the foot gradually to its proper position ; whereas others endeavour 
to effect this at once. The directions of Stromeyer, both as to the 
period for commencing extension and the method of employing it, are 
those which have met with general approval. The extension having 
been commenced, should be daily increased, care being taken not to 
employ it injudiciously, or to apply so great a pressure as to cause 
abrasion or irritation, which might render continuance of the extension 
injurious. The extension is necessary for stretching the ligaments, for 
restoring the bones to their normal position, for elongating the muscles 
on the back of the leg, and for allowing, by bringing up the toes, the 
contraction of the muscles on the front of the leg, by which the foot is 
maintained in its proper position. Together with extension, bathing, 
fomentation, and friction, should be daily employed, and will be found 
beneficial. 



Fig. 124. 



Fig. 125. 




Of the many kinds of mechanism contrived for the pupose of accom- 
plishing extension in the various forms of talipes, Stromeyer's stretching 
board, and Dr. Little's apparatus, are most generally approved. They 



Fig. 124. Little's boot applied, 
view. 



One view. Fig. 125. Little's boot applied. Opposite 



388 TALIPES. 

are the only kinds of which, until lately, I have had experience ; and 
they certainly answer most admirably the purposes for which they are 
intended. The former is the more suitable for talipes equinus, and for 
some cases of talipes varus ; but for others, Dr. Little's apparatus will 
be found more useful, as fulfilling more indications than the stretching- 
board of Stromeyer. These pieces of mechanism, and the mode of their 
operation, may be understood from the accompanying wood-cuts. The 
apparatus of Dr. Little is a modification, with various improvements, of 
one originally used by Scarpa. By means of mechanism, the foot is 
gradually brought into its proper position, and the muscles that are 
undivided, the ligaments, and the lymph effused between the ends of the 
divided tendons, are cautiously extended ; but the use of the apparatus 
should be continued after the foot has been brought into its right posi- 
tion, in order to obviate a tendency to contraction, which continues for 
some time to exist in the effused lymph. When walking is resumed, 
care should be taken to place the foot properly on the ground. In this 
variety of talipes, walking, after the proper period, tends to prevent a 
return of the deformity and to perfect the cure ; and it may be ventured 
upon earlier than in some varieties, which will afterwards be described. 

TALIPES VARUS. 

Symptoms. — While talipes equinus is the most simple, talipes varus 
is by far the most common variety of these deformities. "It is that 
deformity in which the foot," as Dr. Little remarks, " undergoes a three- 
fold alteration of its position in relation to the leg : extension, adduction, 
and a rotation of the foot, somewhat analogous to supination of the hand, 
taking place to a greater or less extent, according to the severity of the 
disease. The heel is drawn upwards (extension), the toe is turned in- 
wards (adduction), and the patient treads on the outer edge of the foot 
only, the inner edge being raised from the ground (rotation). This 
threefold alteration from the natural position of the foot, occasions the 

most serious impediments to steady or 
Fi g- 12C - comfortable walking ; and when the dis- 

ease reaches the highest gradations, the 
foot assumes a frightfully distorted ap- 
pearance." In many instances, the dis- 
tortion is so great that the sole of the foot 
is vertical instead of horizontal; and the 
patient, unable to apply any part of it to 
the ground, supports the weight on the 
outer edge of the foot. The patient, when 
standing, keeps the legs removed from 
each other to balance the weight of the 
body ; the gait is unpleasing and un- 
steady, and walking is rendered not only 
unusually fatiguing, but also very painful 
by the strain upon the foot, and the swell- 
ings which form upon the skin on those 
parts on which the patients tread. The 
foot is preternaturally small, as well as the limb, from the want of proper 
development, and it deviates from the natural condition not only in its 




TALIPES. 389 

relation to the limb, but also in its shape ; for its dorsum presents an 
unusual convexity and the sole a corresponding concavity ; its inner 
edge is short and unusually concave ; its outer edge is convex, and in 
many cases has a semicircular outline, on the middle part of which only 
the patient is able to tread. The patient has no power to bend the foot 
by voluntary effort ; the attempt to do so merely increases the adduc- 
tion. When the deformity is slight, the foot may be brought into a 
natural position, but as soon as the force is removed, it returns to its 
former state. When the deformity is more extensive, the surgeon can- 
not, by taking hold of the foot, bring it into a proper position, and in 
the worst cases he can only move it slightly in the right direction. In 
all circumstances, but especially in attempting to bring the foot to a 
natural position, the tendo Achillis and inner division of the plantar 
fascia, and often the tendon of the tibialis anticus, feel tense under the 
integument. But more particular reference will be made to the struc- 
tures which are shortened, under the head of the abnormal conditions. 

These symptoms may either exist at birth or arise afterwards ; in the 
former case, they constitute talipes varus congenitus, in the latter, 
talipes varus acquisitus. 

Abnormal Conditions. — In talipes varus there are the same abnormal 
conditions of the bones as in talipes equinus. This might have been 
expected, as extreme extension is common to both deformities. It is 
unnecessary again to enumerate these conditions ; but there are also 
other changes in talipes varus, produced by the adduction and rotation. 
The changes, as in talipes equinus, consist principally of alterations 
in the relations of articulating facets to each other. According 
to Scarpa and other anatomists, the astragalus undergoes less altera- 
tion of position than either of the other tarsal bones. Although its 
articulating facets for the ankle joint are displaced by being pressed 
forward and outward, the portions of these surfaces towards the outer 
side being further displaced than those towards the inner, still some 
parts of its surfaces are in contact with some parts of the surfaces for 
the ankle joint furnished by the bones of the leg ; and there is no con- 
dition calculated to prevent a cure, if the cause of the deformity be re- 
moved. The posterior extremity of the calcaneum is drawn upwards 
and a little outwards, and its anterior extremity a little inwards ; and 
the scaphoid, cuneiform, and cuboid bones not only present the same 
peculiarities as in talipes equinus ; but they are also, by the adduction 
and rotation of the foot, twisted inwards and rotated on their own axes ; 
so that their inner edges are in a measure directed upwards, and their 
outer edges downwards. The os scaphoides has been found so much 
drawn inwards, as to have its inner extremity articulating with the an- 
terior part of the malleolus internus, and connected with it by a 
powerful ligament. The os cuboides, instead of articulating with the 
whole of the anterior part of the calcaneum, is more or less separated 
from it above, by* being drawn downwards and inwards ; and sometimes, 
when the deformity has been very great, they have been found in con- 
tact only at the under parts of their articulating facets, — a triangular 
space, the base of which is upwards, intervening between them. The 
above are the essential peculiarities of the bones in talipes varus. Pal- 



390 TALIPES. 

letta, Delpech, Cruveilhier, and others, have found the malleolus in- 
ternus in some instances deficient in size ; and in one case which came 
under my own observation, it was remarkably small ; but this condition 
does not always appear. The ligaments adapted to the altered relations 
of the bones, and the stretching of those which are preternaturally 
short, is one of the causes of uneasiness in the restoration of the foot to 
its proper position, by the treatment after an operation. The abnormal 
conditions of the muscles and tendons are considerable and important, 
since it is by them that the deformity is produced and maintained. 
Some muscles are shorter, others longer than natural, and their equili- 
brium is disturbed. This disturbance may be produced in either of the 
ways mentioned in the description of the abnormal changes in talipes 
equinus. The number of muscles which are contracted varies in dif- 
ferent degrees of the deformity. In many cases, especially when the 
deformity is slight, the gastrocnemii alone are so much contracted as to 
require division of their common tendon ; but in other instances, the 
tendons of the tibialis posticus, flexor longus pollicis, and tibialis anticus, 
require division. The tibialis anticus, although, naturally a flexor of 
the ankle joint, has sometimes, in aggravated cases, its tendons so far 
deflected inwards as to increase the deformity and require division ; 
and in a case in which I lately operated, where the deformity had 
attained its highest grade, the extensor longus pollicis was so far de- 
flected inwards, and so tense, that it was necessary to divide it as well 
as the tibialis anticus, the tendons of the gastrocnemii, the flexor longus 
pollicis, and the tibialis posticus muscles. When the muscles are spas- 
modically contracted, their bellies feel firm and hard to the touch, like 
muscles affected with spasm ; but when the deformity is attended with 
structural shortening, the muscular tissue is in a state of atrophy, both 
its length and thickness being diminished ; and sometimes (though such 
an occurrence is now believed to be very rare), it is converted into a 
fatty substance, constituting what is termed the fatty degeneration. 
There is often shortening of the plantar fascia to such an extent as to 
require the division of its inner portion. This shortening, however, is 
not, as Maisonnabe believed, a cause of the deformity, although it often 
presents such an obstacle to the restoration of the foot to its proper 
position as to render division necessary. The appearance of the limb 
slightly resembles its appearance in a state of atrophy. Its tempera- 
ture is often observed to be lower than natural, and on dissection the 
vessels and nerves, like the other structures, have been found unusually 
small. Of all the abnormal conditions, however, that of the muscles 
and tendons especially requires attention. 

Treatment. — In determining the most prudent method for restoring 
the foot to its natural position, the surgeon will be guided by the same 
considerations as in a case of talipes equinus ; and, as the principles of 
treatment were fully stated under that head, it appears unnecessary to 
do more than to give some short particulars as to the treatment of those 
cases of talipes varus in which there is so much shortening of tendons, 
that their division is requisite, in addition to mechanical treatment, for 
the restoration of the foot, and also to state the most prudent method of 
procedure with congenital cases in infants until the period arrives at 
which an operation may be proper. 



TALIPES. 



391 



With regard to cases which require an operation and mechanical ex- 
tension for the removal of the deformity, the first point is to ascertain 
which tendons ought to be divided ; and this can only be done by a mi- 
nute investigation of the case. As was stated in describing the abnormal 
conditions, in some instances, section of the tendo Achillis is sufficient, 
and in such cases, the operation is precisely the same as for talipes 
equinus. In some of these cases, the difficulty of bringing the foot to 
its natural position is removed on the division of the tendon ; in others, 
a certain amount of resistance is offered by the muscles on the back of 
the leg, but not more than can be removed by mechanical extension. 
There are many cases, however, in which other tendons, besides the 
tendo Achillis, must be divided ; most commonly the tendon of the 
flexor longus pollicis, or of the tibialis posticus, or one or both of these 
tendons belonging to muscles on the back of the leg, together with the 



Fig. 127. 



Fig. 128. 





tendon of the tibialis anticus in front. In a very interesting and satis- 
factory case, which I treated lately, and from which the accompanying 
figures were taken, it was necessary to divide all the above-mentioned 
tendons, namely, three on the back of the leg, and two on the front, that 
of the tibialis anticus, and that of the extensor proprius pollicis. The 
two last-mentioned tendons were so deflected inwards and shortened, as 
to maintain the deformity. Occasionally it is also necessary to divide 
the plantar fascia before the deformity can be entirely removed. In 
Dr. Little's interesting treatise, various cases of talipes varus are re- 
corded, in which a cure was effected by section of the tendo Achillis, 
followed by mechanical extension, and other cases, in which division of 
other tendons also was necessary. In the eighth case recorded in his 
treatise, the deformity was cured by division of the tendo Achillis, and 
tendon of the tibialis posticus ; in the fourteenth case, by division of the 
tendo Achillis and the tendon of the flexor longus pollicis muscle ; in 
the eighteenth, it was cured in one foot by division of the tendo Achillis, 



Fig. 127. Appearance before operation. 

Fig. 128. Appearance a fortnight after operation. 



392 



TALIPES. 



Fig. 129. 



and in the other, by division of the tendo Achillis and tendons of the 
anterior and posterior tibial muscles ; and in the twenty-third case, by 
the division of the same three tendons. More extensive use of the knife 
than is absolutely necessary is exceedingly reprehensible. The division 
of the tendons should be subcutaneous, and effected in the same manner 
as that of the tendo Achillis, and with the least possible injury of the 

common integument, and the sur- 
rounding parts. The tendo Achillis 
may be divided about an inch 
above the calcaneum, or a little 
higher or lower, as the circum- 
stances of the case may indicate ; 
and the most common and advisa- 
ble situations for dividing the other 
tendons are, for the tendons of the 
tibialis anticus and extensor pro- 
prius pollicis muscles, the dorsum of 
the foot in front of the ankle joint, 
where they appear most prominent ; 
for the tendon of the tibialis pos- 
ticus, about an inch above the un- 
der part of the malleolus internus ; 
and for the tendon of the flexor lon- 
gus pollicis in the sole of the foot, where it is found most tense. 
The foot should be allowed to remain in its unnatural position, until 
the small wounds are perfectly cicatrized, when extension should be 




Fis. 130. 



Fig. 131. 




commenced, and gradually and cautiously increased, and constantly 
maintained, until the foot be brought to its proper position. Stro- 



Fig. 129. Appearance six weeks after. 

Figs. 130 and 131. Talipes varus before and after operation. Treated by Aveling's 
talivert. 



TALIPES. 393 

meyer's stretching-board, with a little additional apparatus for more 
efficiently preventing inversion, will be found a very convenient appli- 
ance for satisfactorily fulfilling all the necessary conditions. In slighter 
cases, or after the foot has been brought nearly to its proper position, 
or when the resistance to be overcome is not very great, Little's appa- 
ratus will be found to answer all the purposes aimed at by mechanical 
extension. From the tendency of the foot to turn inwards, patients 
cannot be allowed to resume walking so soon after the operation as they 
may after the operation for the cure of talipes equinus, and when they 
venture to do so, the parts should be for some time supported by a boot 
with a steel spring or stem on the inner side, and the patient should 
very carefully endeavour to place his foot evenly upon the ground, as 
from the laxity of the structures which should keep the foot outwards, 
there is a tendency in the upper part of the tarsus to turn outwards, 
and in the toes to turn inwards. 

As talipes varus is frequently met with in infants, it is important to 
comprehend distinctly the, treatment proper for the % deformity at that 
period. As it is very desirable to avoid the performance of even the 
slightest operation in an infant, it is fortunate that more cases are 
curable without operation in infancy than at a later period of life ; and, 
as the difficulties in carrying out treatment by mechanical extension are 
on many accounts greater, it is a happy circumstance that the resis- 
tance is less in infants than in older patients. Whether a case of talipes 
varus in an infant can be cured by mechanical means, can be deter- 
mined with certainty only by a trial ; but an opinion may be formed by 
observing the amount of resistance offered to the endeavours to place 
the foot in its proper position. The treatment recommended by Dr. 
Little, when the infant is under six months, is to apply tin splints to the 
inner side of the foot, protecting the limb from pressure by the intro- 
duction of cotton wadding, and then to bandage the leg and foot to the 
splint. The effect of the bandage will be to press the inner part of 
the great toe, and the upper and inner part of the leg, against the 
splint, and to diminish the convexity outwards formed by the interme- 
diate parts of the limb. The object aimed at in the first instance is to 
overcome the inclination inwards of the toes, or in other words, to con- 
vert the talipes varus into talipes equinus ; and this having been accom- 
plished, a tin splint with the foot-piece bent more upwards should be 
used for the purpose of bringing down the heel. If the child be more 
than six months of age, he recommends the employment of his own 
apparatus, a representation of which has been already given, for over- 
coming the inclination of the toes inwards, and bringing down the heel. 
It often happens that, while it is possible to overcome the distortion 
inwards, the heel still remains elevated, ' and in such cases, when the 
child is about to walk, the cure may be very quickly completed by 
section of the tendo Achillis. 

TALIPES VALGUS. 

This is much less common than either of the two former varieties of 
these deformities. 



394 



TALIPES. 



Symptoms. — Here 

Fig. 132 




, also, the foot undergoes a threefold alteration of 
its position in relation to the leg, 
but the alterations are the very 
reverse of those in talipes varus. 
The foot is flexed, abducted, and 
rotated outwards. Walking is 
very fatiguing, and in the worst 
cases, the patient can place no 
part of the sole of the foot on the 
ground, but treads upon the inner 
ankle ; the knee of the affected 
side inclines inwards, and the limb 
presents the same appearance of 
atrophy as in the deformities al- 
ready described. This variety 
also may be either congenital, or 
acquired. 

Abnormal Conditions. — I have 
not had any opportunity of ascer- 
taining by dissection the abnormal 
conditions. On this subject, Dr. Little says, "I have been afforded 
only three opportunities of investigating the morbid anatomy of talipes 
valgus ; these were furnished by Professor Miiller, and Dr. Pockels of 
Brunswick. The subjects from which the preparations were taken were 
full-grown foetuses. In these, so far as the incomplete development 
of the osseous structures enabled me to judge, the astragalus was twisted 
in such a manner that the articular facet, which ought to be applied 
against the inside of the internal malleolus, did not enter the composi- 
tion of the ankle-joint, but was turned downwards ; the navicular bone 
and calcaneum followed the astragalus, and together with the internal 
malleolus, would have touched the ground with their internal surfaces, 
if the feet had belonged to subjects who could have walked. The 
external edge of the os cuboides, and fifth metatarsal bone, and external 
surface of the calcaneum, presented directly upwards ; the latter, there- 
fore, was in contact with the external malleolus, the prominence of 
which could not be felt through the skin of the foot." 

Treatment. — The treatment must be conducted on the same principles 
as in the two former varieties. If it be thought that mechanical treat- 
ment alone will be sufficient, a convenient appliance for that purpose 
is Dr. Little's apparatus with the springs on the inner instead of the 
outer side ; and if division of tendons be also required, the same me- 
chanism answers all the purposes of a retentive apparatus. In some 
slight instances, division of the tendo Achillis alone has proved suffi- 
cient ; in others, that of the tendons of the peronei muscles has been 
requisite ; and in others, it has been necessary to divide all the tendons 
of the peronei and gastrocnemii muscles. A convenient situation for 
division of the tendons of the peronei muscles is five or six lines above 
the under part of the malleolus externus. On account of the extreme 
relaxation of the ligaments on the inner side of the foot, it is long before 
the patient can be allowed to walk after the operation. 



TALIPES. 



395 



TALIPES CALCANEUS. 

This appellation was given by Dr. Little to a deformity which he met 
with in a child four and a half years of age, in whom the fore part of 
the foot was elevated to the greatest possible extent, and the heel so 
much depressed as to have the long axis of the calcaneum in a line 
with the leg, and its posterior surface only touching the ground. The 
tendons on the front of the leg were 

tense, and those on the back relax- Fi s- 133 - 

ed ; so much so, indeed, that the 
tendo Achillis could scarcely be 
felt. The foot was easily brought 
into its proper position, which 
proved that there was no structural 
shortening ; and the treatment, 
which was successful, consisted in 
the use of a boot for maintaining 
the foot in its proper position. Dr. 
Little states, that in a French pe- 
riodical, a deformity, believed to 
be of the same kind, is said to have 
been successfully treated by divid- 
ing the tendons of the tibialis anti- 
cus muscle. This is the distortion 
called by some writers hook-foot ; 
the same principles of treatment 
are applicable as in the other forms 
of talipes. 

Having mentioned the symptoms, abnormal conditions, and treatment 
of these deformities, it may be satisfactory to state very shortly the 
views now entertained regarding their origin, and the history of treat- 
ment now so generally and successfully adopted. The opinions that 
talipes is caused by an unnatural form of the tarsal bones, or by an 
alteration of their relative position and connexions, or by an unnatural 
contraction of some ligaments and elongation of others, or that it is 
occasioned by undue pressure on the foetal limbs by the uterus, in con- 
sequence of deficiency of the liquor amnii, or by external pressure to 
conceal pregnancy, or by the limbs being arranged in an improper 
position during foetal life, belong only to the past history of surgery. 
The opinion now generally entertained is, that these affections are 
caused by a disturbance in the equilibrium of antagonizing sets of mus- 
cles. The writings of Duvernay, Tong, Boyer, Rudolphi, Shaw, Del- 
pech, Stromeyer, Guerin, Duval, and some others, have been the means 
of gradually leading to the adoption of this view, to its fuller develop- 
ment, and more lately to its perfect confirmation, together with its prac- 
tical application in the treatment of these affections. Rudolphi ap- 
pears to have held this view more clearly than his predecessors ; 
he contended that congenital talipes proceeds from the disordered 




Fig. 133. From Dr. Little. 



396 TALIPES. 

influence of nerves on muscles during the period of foetal existence. 
Delpech at one time believed that talipes originated in malformation of 
the tarsal bones ; but even then he considered that the muscles contri- 
buted to increase the deformity ; but he stated in his treatise " L'Ortho- 
morphie," published in 1829, that he had renounced his opinion as to 
the origin of the deformity, and that he believed its immediate cause to 
be a disturbance of the natural and necessary equilibrium of the mus- 
cles, which disturbance may have resulted from remote influences, as 
effusion upon the' brain or spinal cord, or from hydrocephalus, or from 
irritation excited in some part of the nervous system, or from direct 
injury of the nerves leading to muscles ; as, for example, in a case in 
which the external popliteal nerve was injured, and the injury was fol- 
lowed by paralysis of the tibialis anticus, extensor proprius pollicis, 
extensor longus digitorum, and peronei muscles, and by contraction of 
their antagonists, and consequent distortion of the foot ; or in a case in 
which talipes varus, in an extreme degree, followed injury of the nerves, 
induced by necrosis and abscess of the femur. Delpech, however, was 
of opinion that the gastrocnemii are the only muscles involved in the 
production of talipes varus, and that the adduction of the foot is caused 
by pressure in walking. Stromeyer believes the contraction of the gas- 
trocnemii to be the essential cause of talipes equinus and talipes varus, 
and the deficiency of the internal malleolus the cause of the inclination 
inwards in talipes varus. He supposes that if the contraction of the 
gastrocnemii occur during the early months of foetal life, talipes varus 
will be the result ; whereas, if it take place at a later period, after the 
malleolus internus is in a measure developed, the deformity will be 
talipes equinus, with or without slight inclination of the foot ; in short, 
he regards contraction of "the gastrocnemii as the essential cause, and 
all varieties as secondary phenomena ; whereas the opinion now gene- 
rally entertained is that which the observations of Guerin, Duval, and 
Little, have established, namely, that the deformity, when superadded 
to retraction of the heel, is to be referred to the action of other muscles 
affected similarly with those which occasion the retraction of the heel. 
Dr. Little has given such a clear exposition of his views in the following 
sentences, that I cannot forbear transcribing them. 

" Let us now fully consider those congenital contractions of the feet 
which depend on derangement of the nervous and muscular systems, and 
ascertain in what way a permanent deformity arises. In the first 
place, we will take a case originating from paralysis of the anterior 
tibial muscle. Here the remote injury, the cause of paralysis, is the 
same as that of paralysis of other parts of the body, namely, inflamma- 
tion and the effusion of blood, or sero-sanguineous or serous fluid, in 
some part of the brain or spinal cord, which compresses or otherwise 
injures the delicate texture of that part of the nervous centre, whence 
the affected muscles derive their nerves. The posterior muscles of the leg 
(those of the calf in particular) having lost their natural antagonists, 
become firmly and permanently contracted, by the constant action of 
their involuntary contractile power, by which the heel is raised from 
the ground, Talipes equinus. At an early period of the disease, this 
contraction may be overcome by forcibly bending the foot w r ith the 



TALIPES. 397 

hand ; but tins, after a time, becomes impossible. The other case, that 
of a Talipes originating from spasm, admits of a different explanation. 
The remote cause resides either in the central organs of the nervous 
system (most probably in the spinal marrow), or it is a disease existing 
in some other organ of the body, affecting peripheral parts of the nervous 
system ; for instance, in some one of the viscera of the chest or abdomen, 
more probably of the latter. From this an injury is propagated to the 
central organ, and is reflected to certain muscles of the leg, which 
become spasmodically contracted. In other words, there may be either 
some deviation from the healthy state in a part of the spinal marrow, 
where the roots of the motor nerves distributed to the muscles of the 
calf are implicated or irritated, causing them to become involuntarily 
contracted ; or there may exist elsewhere some disease, such as irritation 
of the mucous membrane of the alimentary canal by improper or undi- 
gested food, or worms, through which filaments of nerves (named by 
Dr. Hall incident) are excited. These communicate in the spinal cord 
with other filaments — the reflex, or involuntary motor nerves, whereby 
the muscles of the calf are excited to spasmodic action. In this explana- 
tion of the production of non-congenital Talipes I have confined myself 
to the most simple and intelligible form of Talipes equinus. The 
Talipes varus differs only in depending on paralysis or spasm of a larger 
number of muscles. When paralysis is the cause, the peronei muscles 
have lost their power, as well as the anterior tibial, and long extensor 
muscles of the toes. If spasmodic contractions be the cause, the poste- 
rior tibial muscle, long flexor muscle of the great toe, those of the sole 
of the foot, and sometimes the tibialis anticus muscle, are partially 
involved in the production of the deformity. I have here defined the 
manner in which I consider Talipes to arise after birth. Any cause, 
whether paralysis or spasmodic, by which the equilibrium, between 
different sets of muscles that are naturally antagonists, is disturbed, 
produces the distortion vulgarly called club-foot. Other causes, namely, 
those which produce a shortening of the muscles and other soft parts 
upon one side of the leg by disturbing (although in a different manner) 
the antagonism of the muscles, are capable of producing deformities 
similar to those belonging to the genus Talipes. 

"Having thus offered my opinion of the causes of those deformities 
of the feet, which take place after birth, and stated the identity of their 
symptoms, and morbid anatomy with those of the club-foot with which 
children are born, the probability will, I think, appear obvious that the 
remote causes are the same ; but there are other phenomena connected 
with the history of these affections, which render the accuracy of these 
opinions almost capable of demonstration. Foetuses which have suffered 
some evident derangement in the development of the nervous system, 
such as those denominated hemicephalous and acephalous, or affected 
with spina bifida, a,nd those born before the expiration of the natural 
period of utero-gestation, are particularly obnoxious to this deformity of 
the feet. The occurrence of the perfectly analogous deformity of the 
hands, which takes place prior to birth, denominated club-hand, in 
which the flexors and pronators (analogous to the so-called extensors 
and adductors of the foot), are likewise contracted, corroborates the 



398 TALIPES. 

opinion that congenital club-foot depends on spasmodic muscular con- 
traction. In the instances which I have examined of congenital de- 
formity of the hand (club-hand), both in museums and in the living 
subject, the feet were also affected with Talipes, proving the operation 
of a common cause. Other circumstances corroborative of this opinion 
are the co-existence with congenital club-foot of congenital squinting, 
and even congenital stammering or mis-enunciation, diseases which evi- 
dently depend either on increase of the involuntary, or the decrease of 
the voluntary motor powers of the orbital and laryngial muscles. The 
importance of these facts is increased by the observation I have made, 
that non-congenital club-foot is likewise occasionally accompanied with 
strabismus." 

The instances are extremely rare in which congenital Talipes is caused 
by paralysis. 

From the time of Hippocrates until March, 1784, the treatment of 
Talipes consisted in the employment of mechanical pressure, and the 
varieties were merely different contrivances and appliances for facili- 
tating the adoption of the same principles of treatment ; but in 1784, 
the first step was taken towards the present method, a physician of the 
name of Thilenius having suggested the division of the tendons affected 
with shortening; and his suggestion was carried into practice byLorenz, 
a surgeon at Frankfort, in the case of a young lady affected from infancy 
with Talipes varus. The heel descended two inches after the opera- 
tion, and the lady was able to walk on the entire sole. It was the 
tendo Achillis that was divided, and the operation was performed under 
the direction of Thilenius. The division, however, was effected by a 
large wound. The suggestion of Thilenius was also carried into practice 
at a subsequent period by Sartorius, whose method of operating, how- 
ever, was liable to many objections, particularly because he made ex- 
tensive incisions of the superimposed parts, exposed the tendon at the 
part to be divided, and after section of the tendon, immediately at- 
tempted to bring the foot to its proper position. The consequences 
were unfavourable, and such as do not follow the operation of section of 
the tendons as it is practised at the present day. Michalis suggested 
a different method of treatment, which consisted in a partial division of 
the shortened tendon, and bringing the foot to its proper position im- 
mediately after the operation ; he recommended section of the tendon to 
the extent of one-third of its thickness, by which means its strength 
would be materially diminished. He performed his first operation 
in November, 1809. Both Sartorius and Michalis recommended imme- 
diate restoration of the foot to its proper position, the one after com- 
plete, the other after partial division of the tendon ; but neither of their 
methods of treatment met with general adoption or approval. 

Delpech had the merit of conceiving and recommending some new 
and important principles of treatment. Having observed that after 
rupture of the tendo Achillis and some other injuries, the uniting me- 
dium admits of considerable elongation, it occurred to him that the 
same elongation could be obtained after section of the tendo Achillis 
for the cure of Talipes, provided mechanical extension be employed 
before the uniting medium has acquired great strength and firmness. 



TALIPES. 399 

He recommended that the section of the tendon should be effected with- 
out division of the common integument over it : and in the instance in 
which he performed the operation, he made a wound of the common 
integument an inch in length on each side of the tendo Achillis by 
passing a scalpel between it and the deeper-seated structures ; and then 
by a convex edged bistoury, he divided the tendon from before back- 
wards. He recommended that after the operation, the cut portions 
should be preserved in apposition, by maintaining the foot in the dis- 
torted position by mechanism, until reunion of the divided tendon be 
effected — that careful and gradual extension of the uniting medium 
should then be made, until the tendon be of sufficient length ; and this 
having been obtained, that the limb be kept in a proper position by 
means of apparatus until the new substance has acquired sufficient 
strength. Delpech performed his operation in May, 1816, and although 
a cure was effected after a long period, and the patient ultimately re- 
covered, yet there were so many discouraging circumstances, that he 
never repeated his operation. Although the mode of dividing the ten- 
don recommended by Delpech is exceedingly objectionable, he certainly 
has the merit of having suggested some important principles in the 
after treatment. To Strom eyer, who performed his first operation in 
February, 1831, the praise belongs of having perceived what was ob- 
jectional, and appreciated what was valuable, in the views of those who 
preceded him, and of proposing and performing the safe and successful 
operation, and the mode of after treatment, which are now so generally 
approved of, and so successfully adopted. 

Before concluding this chapter, I may mention that my friend and 
former pupil, Dr. Aveling, has contrived an admirable apparatus which 
he calls a talivert, and which I have repeatedly used in private and in 
public practice. It appears to me exceedingly well adapted for the 
purposes for which it is intended, and very superior to all kinds of 
apparatus hitherto employed for the treatment of these deformities. I 
hope that Dr. Aveling, who is now practising in Kent, Avill make this 
useful addition to surgical mechanism known to the profession. 



400 



CHAPTER XII. 

DISEASES OF THE ARTERIES. 

ARTERITIS. 

Arteritis may be in activity, acute or chronic : and in extent general, 
invading a large portion of the arterial system, or partial, confined to 
the trunks and branches of a particular part. 

Symptoms and Morbid Appearances, — The symptoms vary according 
to the intensity of the attack, the stage of the disease, and the changes 
occasioned by the inflammation in the affected vessels. The diagnosis 
is often, especially at an early period, extremely difficult : for as the 
disease in some forms presents no signs peculiar to itself, it is not easily 
distinguished from common inflammation. While the disease is still 
slight, and no such changes have occurred in the coats or contents of 
the vessels as to obstruct their canals, the principal symptom is pain 
along the track of the vessels, which pain is increased by pressure, 
motion, or extension of the affected part. On laying the finger over 
the course of the vessel, the pulsation is felt to be weak, and to convey 
a tremulous sensation. When the Arteritis is more severe, and invades 
a part of the arterial system, as for example, when it is seated in the 
arteries of a limb, and the inflammation is so intense as to give rise to 
changes which will presently be described, the pain and tenderness are 
much increased ; an incompressible hardness is felt in the situation of 
the principal arterial trunks affected ; and the pulsation, at first pre- 
senting the peculiarity above-mentioned, by and by ceases entirely. 
Together with these symptoms in the tracks of the main trunks, there 
will, also, be pain in the limb, accompanied with a purplish red appear- 
ance, and oedematous swelling : and if the collateral branches be affected 
the part will exhibit the usual symptoms of gangrene. If the arteritis 
be but to a slight extent, there may be little or no constitutional dis- 
turbance ; but when it is intense, so as materially to impede the func- 
tions of the trunks and collateral vessels, there will, in addition to the 
local symptoms, be those of irritative fever. 

Some years ago I met with a striking example of acute idiopathic 
Arteritis in a female, about thirty years of age, who had previously 
enjoyed uninterrupted good health, except that some years before, she 
had suffered from an attack of acute rheumatism ; but from this she had 
recovered, and had been for years perfectly well. I was called to see 
her in consequence of severe pain in the forearm and lower part of the 
arm, which commenced very suddenly about three hours before I saw 



DISEASES OF ARTERIES. 401 

her. At first the pain was chiefly along the course of the radial and 
ulnar arteries, the pulsation of which vessels at the time I saw her was 
feeble, and that of the humeral artery was labouring. The pain soon 
became diffused over the under part of the arm, the forearm, and hand, 
and was of a bursting character, with oedematous swelling, and a pur- 
plish discoloration of all parts below the commencement of the lower 
fifth of the arm. In the course of eight hours from the beginning of 
the attack, the pulsation of the radial and ulnar arteries, and of the 
humeral artery in the two lower thirds of the arm, entirely ceased, and 
the parts exhibited the ordinary appearance of what is now usually de- 
nominated spontaneous gangrene, — the line of demarcation presenting 
itself at the commencement of the lower fifth of the arm. After some 
days, it was deemed advisable, by an experienced surgeon and myself, 
to perform amputation about the middle of the arm. This was done, 
and the patient recovered, and continued perfectly well for two years, 
when she left Aberdeen with the intention of residing with her relations 
in a distant part of the country. The day after her journey she was 
seized with symptoms in both her lower extremities, similar to those 
which she had previously had in her arm, and in the course of twenty- 
four hours nearly the whole of both lower extremities presented the 
characters of gangrene, and the patient died some hours afterwards. 
This case furnishes a striking example of the serious consequences 
which sometimes result from Arteritis ; and in the latter part of its 
history, a remarkable instance of the truth of the observation made by 
M. Bizot, as to the symmetrical occurrence of arterial disease. Dupuy- 
tren was the first who ascribed spontaneous gangrene to Arteritis. 
The same view was supported by Cruveilhier, who from observations 
on the human body, and from numerous experiments in which he 
excited Arteritis in the lower animals, by injecting irritating fluids into 
the arteries of their extremities, came to the conclusion that the essen- 
tial character of inflammation of an artery is coagulation of the blood 
within it, and that gangrene is the result of occlusion, not only of the 
trunks, but also of the collateral branches. The writer of an able 
article on Arteritis in the " Cyclopaedia of Practical Surgery," speaking 
of the gangrene produced by Arteritis under the expression " particular 
form of gangrene," states his opinion, that it is by no means identical 
with the affection known in this country as Pott's Mortification of the 
Toes and Feet. I have seen examples of Pott's Mortification corre- 
sponding most minutely with the description of the disease in the third 
volume of "Pott's Surgical Works;" but the distinctive characters of 
that affection are quite different from those of spontaneous gangrene 
produced by Arteritis ; the latter affection being much quicker in its 
progress, and, as far as my own experience has given me the opportu- 
nity of judging, far more painful and dangerous. It is stated, however, 
by the writer of the article in the " Cyclopaedia of Practical Surgery," 
that the gangrene from arteritis is less painful than the mortification 
described by Pott. In the case already referred to, I found, on a 
careful dissection of the arteries, that their coats presented a red in- 
flamed appearance, as though some irritating fluid had been injected 
into them ; they seemed to be softer and thicker than natural ; the 

26 



402 DISEASES OF ARTERIES. 

canals, which seemed large, were filled with coagulated blood, and at 
many points there was a slight lamella of lymph on the internal mem- 
brane. No adhesions were perceptible between the coagulum and 
lymph ; but in some examples of this form of Arteritis adhesions are 
said to have been observed. That the coagulum was formed at an 
early period is certain, from the cessation of the pulsation. 

Such were the symptoms and morbid appearances in a well-marked 
example of what may be termed acute idiopathic fibrinous arteritis. 

Treatment. — This form of arteritis should be treated on the same 
general principles as inflammation of other parts, namely, by general 
and local depletion, purgatives, antimonials, diaphoretics, low diet, and 
the occasional use of opiates for relieving the violent pain. Perfect 
tranquillity of body and mind should be strictly enjoined, as any exer- 
tion or emotion which would accelerate the circulation, would, by 
increasing the distension of the vessels, aggravate the disease. The 
prompt but judicious exhibition of mercury, unless an irritable, shattered, 
or scrofulous constitution should forbid its employment, is calculated to 
be highly beneficial by checking inflammation and diminishing fibrinous 
effusion. In the way of local remedies at an early stage, perfect rest 
of the affected part, depletion by leeches, attention to attitude, and the 
use of warm and emollient applications are very important. 

ACUTE SUPPURATIVE ARTERITIS. 

In individuals of shattered, or weak, or cachectic constitutions, a very 
dangerous form of acute arteritis sometimes, though very rarely, takes 
place, and gives rise to phenomena, which in many respects resemble 
those consequent on diffuse suppurative phlebitis. It is much more rare 
than the latter affection, in consequence of the structures which enter 
into the formation of an artery being less susceptible of inflammation in 
any of its forms than those which form the coats of veins. The inflam- 
mation has a tendency to spread from the part first affected. It is 
extremely acute, and is believed to cause the formation of purulent 
matter at an early period. This by being mixed with the blood in its 
circulation, is thought to give rise to the peculiarity of the constitutional 
symptoms, which often prove speedily fatal before gangrene has taken 
place. Violent irritative fever attends the very commencement of this 
disease ; and it very speedily assumes the worst form of atonic or typhoid 
fever. Some of the most remarkable features attending its progress 
are, extreme prostration of the vital powers ; a weak, quick, and small 
pulse ; a pallid and shrunk countenance, expressive of suffering ; a dull, 
lurid, dirty-looking hue of the surface of the body ; a morbid state of all 
the secretions ; flaccidity of the soft solids ; a dry and encrusted tongue ; 
low delirium ; and other symptoms indicative of extreme depression of 
the vital powers. As there is no fibrinous effusion, and in the extremely 
depressed state of the vital powers, little or no tendency to coagulation 
of the blood, there is direct purulent admixture with the blood, in con- 
sequence of the circulation through the inflamed part not being inter- 
rupted. The principal peculiarities of this form of arteritis are, its 
tendency to become diffuse, to go on to suppuration, and if the patient 
survive any length of time, to terminate in gangrene as its most usual 



DISEASES OF ARTERIES. 403 

local result, and the very early change of the acute irritative fever to 
one of the typhoid type. The lesions occasioned by acute suppurative 
arteritis consist chiefly of a dark red, or purple-coloured injection of the 
walls of the vessel, seen on examining its interior, softening of its more 
internal textures, and sanious infiltration into them in various situations. 
Treatment — The same local treatment should be adopted as in the 
variety of arteritis formerly described, together with general antiphlo- 
gistic treatment at the very commencement ; but in prescribing remedies 
of this character it is necessary, even from the very first, carefully to 
keep in view the peculiarity of constitution possessed by most of those 
who are attacked by this disease, as well as the danger arising from 
exhaustion at a more advanced stage. However needful it may be at 
first to use means which produce a relaxing effect upon the capillary 
vessels, promote secretion, soothe nervous irritation, equalize the circu- 
lation, and facilitate the excretory actions, still when the accompanying 
fever assumes the typhoid type, those adapted to the state of depression 
and exhaustion, and calculated to support the vital powers, should be 
actively administered, however little hope there may be of averting an 
unfavourable result. 

ARTERITIS LIMITED TO A PART OF A VESSEL. 

This form of arteritis almost always arises from causes which are 
external and local in their operation, as a wound, or the application of 
a ligature ; and it assumes the sthenic character, and usually gives rise 
to changes which result from that form of inflammation. 

The local results are various, being regulated to a considerable extent 
by the manner in which the injury is inflicted, and the amount of in- 
flammatory action induced. On this subject, Professor Miller says, 
" The minor grades will give exudation of a plastic kind, such as we 
desiderate after deligation ; the coats become turgid and coherent ; and 
the canal is completely obliterated at the part affected. A higher grade 
of action, reaching the truly inflammatory, gives suppuration, usually 
conjoined with ulceration ; a result which we do not desiderate, but on 
the contrary take every means to avoid, in operations on the larger 
vessels ; hemorrhage being almost certain to follow. A still higher 
action, more especially if combined with circumstances tending to im- 
pair vital power of the tissue, causes gangrene of the vessel, a still more 
disastrous event ; exemplified by the deligation of an artery whose coats 
have been too rudely manipulated, and too extensively separated from 
their cellular connexions." 

Much insight into the nature and results of adhesive inflammation, 
by which arteries are obliterated, has been obtained by observing the 
results of that process on the coats and contents of an artery at different 
periods after the application of a ligature. Two of the most attentive 
observers of that process were Jones, who investigated it through its 
different stages, and Stilling, who mentions seventy experiments on 
animals, — experiments which were judiciously conceived and carefully 
performed, and by their results as well as by those of Jones's investiga- 
tions, many important facts have been ascertained and elucidated. Ac- 



404 DISEASES OF ARTERIES. 

cording to Stilling, of whose researches those of others, so far as they 
go, are confirmative, some of the most important changes after the 
deligation of an artery are the following. On tying an artery tightly 
with a small ligature, its two inner coats are cut through^ and the canal 
of the artery is closed by the apposition of the opposite sides of the 
outer coat, and immediately after deligation, stagnation ensues to the 
next collateral branches, with accumulation of blood-globules near the 
ligature, followed by coagulation of fibrin from the fluid constituents of 
the blood. The coagulum is, during the first eighteen hours, of the 
form of a cone, with its apex towards the heart, attached only by its 
base to the part where the ligature is applied ; of very slight cohesion, 
and not of uniform colour throughout, being red towards its base, and 
of a yellowish colour like that of inflammatory crust towards its apex. 
It next undergoes a change of form, of firmness, and of colour ; its 
form becomes more spindle-shaped, the end nearest to the ligature 
tapering less than the other ; its firmness increases partly in conse- 
quence of stronger coagulation, and partly from effusion from the pa- 
rietes of the artery ; and its colour becomes an almost uniform pink or 
red. It by and by becomes attached to the parietes of the artery, the 
attachment being produced by exudation from the vessel, and the adhe- 
sions present a filamentous appearance when the plug is detached from 
the interior of the artery. Stilling, and Dr. Hassie, Professor of Pa- 
thology and Clinical Medicine in the University of Zurich, both state 
that when there has been much exudation, the plug exhibits externally 
several concentric layers. The outer coat being deprived of its nutri- 
tion ultimately gives way. Exudation of lymph takes place into the 
cellular tissue surrounding the artery — its different coats can no longer 
be distinguished, and sooner or later, the thin exudation of lymph exte- 
rior to the portion of coagulum formed by the coagulation of the blood, 
the walls of the artery, and the surrounding cellular tissue become con- 
densed into one mass, in which the original parts can no longer be 
distinguished. Plastic exudation takes place from the extremities of 
the middle and inner coat divided at the line of deligation, and the 
ligature, after severing the outer coat, comes away. The condensed 
mass formed of the exudation from the coats of the artery on the exte- 
rior of the coagulum, the walls of the artery, and the infiltrated cellular 
tissue, are proved by injection to be highly vascular; and that the 
vessels extend into the coagulum, is demonstrated by the vivid colour 
communicated to the latter in successful injections, — the appearance 
being such as, in the opinion of Stilling, to leave no doubt whatever of 
its being produced by vessels, and not by extravasation. The coagulum 
at this stage is traversed with innumerable canals which give it a porous 
appearance, and ultimately it is entirely removed, so that the sides of 
the artery finally cohere. The cohesion is not only where the coagulum 
at one time existed, but it extends also a little nearer to the heart. The 
artery is thus ultimately obliterated. Some observers, in describing the 
different exudations, name the exudation into the surrounding cellular 
tissue and around the artery, the external coagulum ; that from the 
extremities of the divided coats, the middle coagulum ; and that within, 



DISEASES OF ARTERIES. 405 

the internal coagulum. In interfering with an artery, the utmost cau- 
tion is necessary, not only that it may not be extensively detached from 
its surrounding connexions, whereby its coats would be deprived of their 
nutritious vessels ; but also that nothing but the most gentle manipula- 
tion be employed, so that there may be as little danger as possible of 
the supervening action going beyond the adhesive grade. 

CHRONIC ARTERITIS. 

Chronic arteritis presents no distictly appreciable signs, or they are 
so slight, and of so equivocal a character that they commonly escape 
detection, until the lesion with which they are connected has increased 
so far as seriously to disturb the functions of the part. The question, 
whether chronic arteritis stands in any casual relation to certain organic 
lesions, with which at one period of their history it is undoubtedly con- 
nected, will be considered, when the nature and appearances of those 
lesions are described. 

LESIONS OF THE COATS OF ARTERIES. 

CARTILAGINOUS DEGENERATION: OR, CARTILAGINOUS PATCHES UPON THE 
FREE SURFACE OF THE INTERNAL ARTERIAL MEMBRANE. 

These formations occur most frequently before or about the middle 
period of life, and chiefly in the smaller arteries at a considerable 
distance from the heart ; occasionally they are found in the larger 
arteries, and in such instances they occur at the point where branches 
originate. These deposits present considerable varieties as to their 
transparency, consistence, and connexion with the inner membrane ; 
sometimes they are transparent, of a semi-fluid consistence, and sepa- 
rable, so that they can be peeled off, leaving the internal membrane 
entire ; sometimes they are less transparent, of the consistence of boiled 
white of egg, and can scarcely be peeled off without removing that coat ; 
in other instances, they are opaque, of the appearance of cartilage, with 
the lining membrane no longer discernible, and on the removal of the 
deposit, the middle coat is brought into view. These varieties are 
regarded as the different degrees of the same affection, which commences 
with albuminous effusion, the effusion gradually becoming more opaque 
and firmer in consistency, and more completely involving the internal 
arterial membrane. The only change these patches seem to undergo 
after assuming a cartilaginous consistency, is increase of thickness. 
The internal membrane, probably from having lost its elasticity, some- 
times cracks around these bodies, which consequently hang into the 
artery, and in such circumstances, fibrinous coagula are apt to be 
deposited round their margins. Professor Hassie, of Zurich, states that 
he had twice found this condition in the abdominal aorta. I have, in 
my own collection, a beautiful preparation of the aorta, which strikingly 
exhibits this lesion. The opinions which at one time prevailed, that 
these cartilaginous patches originated between the internal and middle 
membranes, and that they are occasionally converted into osseous sub- 
stances — that, in short, they form a preparatory stage to ossification, 



406 DISEASES OF ARTERIES. 

are now believed to be erroneous. These opinions, no doubt, arose from 
the occasional occurrence of cartilaginous degeneration of the internal 
membrane, coexisting with osseous formation between the inner and 
middle coats ; but the latter differ remarkably from the former in their 
origin, mode of development, and the consequences to which they give 
rise, as will afterwards be stated. As to the nature of the morbid 
process, by which cartilaginous degeneration of the internal membrane 
is produced, pathologists are- not agreed. Professor Hassie thinks they 
are deposited immediately from the blood circulating through the vessels. 
Hodgson says — " The surrounding parts of the membrane generally 
exhibit the appearances of chronic inflammation, but I have never seen 
red vessels on that portion of the internal coat which had been converted 
into this cartilaginous structure." Bizot, who examined the arterial 
system in one hundred and fifty-two subjects, and minutely investigated 
its morbid conditions, gives a clear description of the anatomical charac- 
ters of this comparatively rare degeneration of the internal coat, and 
regards it as a product of inflammation of that coat. It may be said to 
have been proved by M. Bizot, who traced the transformation step by 
step, that the patches originate in the albuminous exudation of arteritis, 
which exudation is at first of a viscid gelatinous consistence, but gradu- 
ally becomes firmer, and eventually supplants the inner membrane, on 
the free surface of which it was originally effused. 

STEATOMATOUS DEGENERATION. 

This disease, named less properly by some atheromatous degeneration, 
was long overlooked, and seems to have been first noticed by Monro 
and Haller ; but since they drew attention to it, it has been investi- 
gated with great success by many able pathologists, and its anatomical 
characters and progress distinctly pointed out. Steatomatous degene- 
ration commences by minute granules, of a pale yellowish colour, 
situated between the internal and middle coats. While the disease is in 
this rudimentary state, the lining membrane is scarcely elevated at all ; 
it is transparent, so that the spots are seen through it ; it is unchanged 
in consistence ; and if it be peeled off, the granules being adherent to its 
surface, come along with it. There is no accompanying redness, or any 
mark of inflammatory action in the surrounding textures. These granules 
coalesce into groups or masses, in the next grade of the degeneration, 
and the inner membrane, though unchanged as to transparency or 
texture, is scarcely so flat as during the early stage ; and if it be peeled 
off, part of the deposit comes away with it, and part clings to the middle 
coat, from which it appears obvious, that the unnatural deposit is deve- 
loped between them. The. middle coat, at the seat of the deposit, is of 
a light yellow colour, and of a more friable texture than natural, but 
neither in it nor in the surrounding textures can traces of inflammatory 
action be at this stage discovered. The deposit has the consistence of 
suet — feels greasy to the touch — is of a cheese-like opaque appearance, 
and when broken down by the finger, gives the sensation of minute 
granules scattered through a fatty substance. Not only has it a fatty 
appearance, but the researches of Gulliver show that its chemical com- 



DISEASES OF ARTERIES. 



407 



Fig. 134. 



position also differs but little from that of ordinary fat ; and this being 
the case, of the two appellations, steatomatous and atheromatous degene- 
ration, the former is the more correct. Bizot detected shining particles 
in this deposit ; Cruveilhier, small masses resembling the cholesterin 
scales of small gall-stones. Gluge, on examining these masses with the 
microscope, found them to consist of fat-globules; and Sivaine, who 
also repeatedly examined them with the microscope, states that he 
" found them, on several occasions, to consist of fat-globules merely ; 
generally, however, they were made up of an amorphous granular mass, 
mingled partly with fat-drops, partly with numerous cholesterin rhom- 
boids. The shining particles are often very numerous, some having a 
golden, and some a silvery hue." 

The steatomatous degeneration, after attaining the grade last described, 
may undergo one or other of various transformations ; the two principal 
changes, however, are ulcerous softening and osseous transformation. 
For the sake of a clearer description, the various changes in ulcerous 
softening have been arranged into three stages. 
The first is characterized by the absence of all marks 
of inflammation in the surrounding textures, or of 
any change in colour, transparency, or consistency 
of the internal membrane. This membrane, how- 
ever, is slightly elevated, there being more of the 
deposit than in the former grades of the disease , 
and the middle coat is still more altered and 
softened, and of a still brighter yellow colour at the 
affected spot. In the second stage, the patches are 
distinctly elevated, like pustules, and when pressed, 
communicate to the finger of the examiner the im- 
pression of their containing a semi-fluid substance. 
After the membrane has been opened and the matter 
discharged, it is found on examining the place in 
which the matter was contained, that the middle 
coat presents an ulcerated appearance ; but some 
part of it still remains between the place in which 
the matter was situated and the outer coat. In the 
third stage, the internal membrane having cracked 
allows an escape of the deposit, and falls down towards the middle coat, 
producing a depression ; or the internal membrane having (as happens 
in many instances) fallen off, or having disappeared, an ulcer is formed, 
with the walls of which the sanguineous current is in contact, the edges 
being irregular, and the walls formed of the outer coat, or of that and 
the yellowish detritus of some very small portion of the middle coat. 
The outer coat becomes thickened, and the seat of many injected vessels, 
but no traces of inflammation are to be seen in the inner and middle 
coats at the parts surrounding the seat of the degeneration. Such are 
the characters of the steatomatous degeneration, when it undergoes the 
ulcerous transformation ; but, as has been stated above, it may undergo 




Fig. 134. From a preparation in my museum. 



408 



DISEASES OP ARTERIES. 



an opposite change, termed the osseous transformation. The term 

transformation has been objected 
Fi g- 135 - to, when applied to this last-men- 

tioned change, as the calcareous 
matter is merely deposited in the 
yellow steatomatous substance, 
which is regarded by many patho- 
logists as forming its nidus. The 
calcareous matter assumes the 
form of thin, brittle scales or 
plates, of a yellowish-white colour, 
surrounded at first by steatoma- 
tous deposit, but not having any 
fibres or organized structures be- 
tween them. They are believed 
to increase very slowly, the sur- 
face directed to the lining mem- 
brane more slowly than that 
directed outwards ; and they evi- 
dently enlarge more in extent than 
in thickness. As the calcareous 
deposit increases, it comes into 
contact with the lining membrane, 
from which it is in some instances 
separated up to this period by a 
layer of albuminous matter spread 
over it. The inner membrane in 
many cases at length gives way, 
so that the blood is in immediate 
contact with the calcareous deposit, 
and the middle coat, after having 
been attenuated and changed as 
already described, ultimately disappears, and its place may be said to 
be occupied by the concretion ; hence has arisen the erroneous opinion 
that this coat itself is transformed into bone. The calcareous concretions 
are found in various forms ; they usually consist of plates or scales, 
varying considerably in extent, and in some rare instances, occupying 
the whole circumference of the vessel at the affected part, so as to con- 
vert it into an inflexible tube. Sometimes they consist of minute 
grains ; and more rarely, they give, on examination with the finger, the 
sensation of a number of minute bodies, movable on each other, as if 
jointed together. As cartilaginous degeneration of the inner coat is not 
very unfrequently found coexisting with the form of calcareous trans- 
formation just described, the error of ascribing the calcareous deposit 
to ossification of the previously-existing cartilage is easily accounted for. 
These subjects of anatomico-pathological investigation have occupied the 
attention of many pathologists, and in the present state of our know- 
ledge of them, they are considered, not as different stages of the same 




Fig. 133. From a preparation in my museum. 



DISEASES OF ARTERIES. 409 

disease, but as entirely different diseases — the result of different morbid 
actions ; the one commencing on the free surface of the internal coat, 
the other in the cellular tissue betAveen the internal and middle mem- 
branes. Such are the anatomical characters of the ulcerous and calca- 
reous transformations ; the latter, however, may give rise to ulceration, 
and it may therefore be stated, that, in the progress of steatomatous de- 
generation, ulcerous transformation may take place, with or without 
osseous transformation. Sometimes when the steatomatous deposit ex- 
ists in great quantity, it diminishes the channel of the artery, but it is 
much more frequently productive of dilatation with or without ulcera- 
tion, or of rupture, or of circumscribed or diffuse false aneurism — dila- 
tation being usually the result of the steatomatous deposit, and rupture 
with its consequences, of that condition when accompanied by calcareous 
concretion. A variety of the steatomatous deposit has been described 
by Scarpa, Stentzel, Craigie, and others, in which the secretion is of a 
yellowish colour, and of a cheesy or wax-like consistency. It commences 
most frequently in the bifurcations of arteries, and , originates between 
the middle and inner coats ; but it differs from the deposit already de- 
scribed, in being of firmer consistence, and in rarely containing gritty 
calcareous deposition. To this variety some restrict the term steato- 
matous degeneration, and give to that already described the name of 
atheromatous deposit. 

CALCAREOUS DEGENERATION. 

Calcareous degeneration has been referred to by authors under the 
various names of ossification, earthy degeneration, calcareous deposit, 
and osseous transformation. One variety of this disease, namely, that 
which is often found to occur as a transformation in the progress of 
steatomatous degeneration, has already been described ; but there is 
another form, differing from this in many important particulars. Its 
seat is in the middle coat itself ; it appears in the form of plates or 
spicula, occupying a greater or less extent of vessel, and in some 
examples, it at last becomes so extensive and complete as to convert the 
affected part of the artery into an inert tube. This degeneration seldom 
affects the whole circumference of an artery, except in the lower extre- 
mities, where it has been found to exist in distinct rings. The middle 
coat loses its equable aspect, some of its fibres shrivel, and the coat 
consequently becomes thin. It is yellower than natural, and instead of 
being elastic, it becomes friable and easily torn. If at this period, the 
vessel be cut in the direction of its length, the margins of the incision 
appear irregular, from the change not having been uniform, some fibres 
having lost more of their elasticity than others. Such are the early 
deviations from the healthy appearance of the middle coat, the fibres of 
which are ultimately changed into, and their place occupied by, an 
osseous formation. In consequence of this change, the external surface 
of the artery, in ' many instances, presents an uneven appearance, 
becoming unequally dilated in some parts, and slightly constricted in 
others. The internal coat, while the disease is limited and of recent 
standing, may remain entire, though shrivelled and irregular ; but in an 
advanced stage, the inner surface of the vessel often becomes ragged 
and irregular — a result of the rupture of the internal membrane at the 



410 ANEURISM. 

margins of the calcareous deposit. The morbid change now under con- 
sideration is most frequently found in the arteries of the lower extre- 
mities and of the brain ; and the steatomatous degeneration most fre- 
quently in the aorta. Dilatation and aneurism are more rarely caused 
by the calcareous than by the steatomatous degeneration. In individuals 
at an advanced period of life, the calcareous degeneration not unfre- 
quently produces in the lower extremities gangrene of feet and limbs, 
and in the vessels of the brain rupture, ending in fatal extravasation of 
blood and compression of the brain. Another consequence of this 
degeneration is hemorrhage after the deligation of an artery ; the vessel 
cracks at the part where the ligature is applied, adhesion does not 
follow, and ulceration and hemorrhage result. The steatomatous dege- 
neration and its various sequelae are occasionally coexistent with the 
calcareous. Although the calcareous deposition is a form of ossifica- 
tion, yet it differs from bone in several essential particulars ; it is desti- 
tute of fibrous structure and of vascularity ; it presents an irregular 
homogeneous appearance ; it consists of a larger portion of phosphate of 
lime and less animal matter ; and it is destitute of any obvious arrange- 
ment. The period of life at which calcareous degeneration usually 
occurs is after the sixtieth year. Instances, however, are recorded, of 
its having been met with in infants, in children, and in persons from 
eighteen to twenty-four years of age ; but such examples are regarded 
as exceptions, and are extremely rare. As increased vascular action 
frequently exists without calcareous degeneration, and as that degenera- 
tion, in its early stage, is unattended with any traces of inflammation 
(although, when extensive, it may operate as a foreign body, and excite 
chronic inflammatory action), there appears no reason to regard this 
disease as a consequence of inflammation ; especially as it usually occurs 
at that period of life at which there is the least tendency to inflamma- 
tion. It is considered to be a result of an alteration of the process of 
nutrition, but with what morbid condition of the system it is connected, 
pathologists have not been able to determine. 

ANEURISM. 

By the term aneurism, derived from the Greek *vew'f «j>«, signifying a 
dilatation, is meant a pulsating tumour containing blood, and communi- 
cating with the interior of an artery. 

I. Divisions. — Various divisions have been made of aneurisms. Some 
writers, taking situation as the basis of arrangement, have divided them 
into internal, or inaccessible ; and external, or accessible. By an 
external or accessible aneurism is meant an aneurism so situated, that 
it is impossible to include the trunk of an affected artery in a ligature, 
between the aneurism and the heart : where this is impossible, the 
aneurism is termed internal, or inaccessible. To the latter class belong 
aneurisms in the cavities of the body, as in the abdomen, chest, and 
cranium. Another division is based on the manner in which the aneurism 
is formed, and the tissue constituting the aneurismal sac. According 
to this arrangement, which is both ancient and useful, all aneurisms may 
be arranged into two classes — true and false. Much confusion, however, 
has arisen from systematic writers attaching different meanings to these 
terms. By a true aneurism, some authors mean one in which the aneuris- 



ANEURISM. 411 

mal sac is formed by simultaneous dilatation of all the coats of an artery; 
and by a false aneurism, one in which, after the destruction of the inner 
and middle coats, and the ultimate giving way of the outer coat, some 
other tissue forms the aneurismal sac. Other writers, by a true aneu- 
rism, mean one which results from disease of an artery, and formed by 
dilatation of all the coats, or in consequence of ulceration from within, or 
by rupture, or by ulceration and rupture jointly, while some of the coats, 
remaining undivided, form the aneurismal sac ; by a false aneurism, 
they understand one in which some other tissue, or tissues, form the 
aneurismal cyst, all the coats having been divided by a wound, or 
destroyed by ulceration from without. Another classification, adopted 
by many writers, divides aneurisms into true, false, and mixed; the 
true being those in which all the coats are dilated and form the sac ; 
the false, those in which all the coats are destroyed at some part, and 
the surrounding tissues form the cyst; and the mixed, those in which 
the coats of the vessel are first dilated and subsequently destroyed, the 
disease being at first a true, and afterwards changing into a false, 
aneurism. Cruveilhier, from finding the imperfections of other classi- 
fications and of the difficulty of ascertaining beyond doubt the state of 
the arterial coats, by which alone could be formed a classification 
founded on a pathological basis, proposed an arrangement based entirely 
on outward form ; namely, A. Aneurismes sous 1'aspect d'ampoules ; 
1. Aneurismes Periphe'riques ; 2. Aneurismes Semipe'riphe'riques ; 3. 
Aneurismes a Bosselures. B. Aneurismes sous 1'aspect de Poches a 
Collets. 

TRUE ANEURISMS. 

II. Mode of Formation. — True aneurisms may be formed in various 
ways: 

1. By Dilatation. — It has been clearly proved by various dissections, 
in which the true arterial coats have been traced in unbroken continuity 
through the parietes of the sac, that aneurisms are sometimes formed 
without any rupture by dilatation of all the coats. This doctrine, 
advanced by Fernelius, Diemerbrock, Haller, and others, was called in 
question by Scarpa, who conceived that true aneurisms are always 
formed by destruction of some of the tunics of an artery. The opinion 
of Scarpa, however, was successfully combatted by Hodgson, who by 
minutely examining numerous preparations in the different museums in 
London, and by carefully dissecting many aneurisms in their different 
stages of formation, ascertained that although in the majority of 
instances, especially when aneurisms have attained a considerable size, 
the coats of the vessel have given way, still many aneurisms are formed 
by dilatation, and that Scarpa therefore was on this point certainly in 
error. The dilated coats in some instances appear little altered in 
thickness, but more frequently they are attenuated in some parts, and 
thickened in others. The dilatation may affect only a limited portion 
of the circumference of the artery, constituting what from its form is 
called a sacculated or sacciform aneurism ; or it may implicate the whole 
circumference and affect the artery to a considerable extent longitudi- 
nally, constituting when regular in its outline and abrupt at its extremi- 
ties, a cylindrical aneurism ; or it may commence and terminate gra- 



412 ANEURISM. 

dually, in which case it is called a fusiform aneurism ; or it may be very 
irregular, giving to the artery a knotty and tortuous appearance, con- 
stituting what Breschet has denominated the varicose form of true 
aneurism. The formation of aneurism by dilatation is often observed 
in the aorta. 

2. By Rupture. — If an artery, affected with any of the forms of 
degeneration formerly described, be violently stretched, as in leaping, 
running, or by any violent exertion in walking, then the inner and 
middle coats may become lacerated, the diseased condition may prevent 
adhesion, and the result may be the dilatation and ultimately the giving 
way of the outer coat. The doctrine that aneurism was formed by rup- 
ture of the coats of an artery was maintained by Sennertus, Hildanus, 
Severinus, and others. It is usually called, however, the doctrine of 
Sennertus, and has been ably supported by Scarpa, who contended that 
aneurism is formed " by a corrosion and rupture of the proper coats of 
the artery, and consequently by effusion of blood under the cellular 
sheath, or any other membrane which covers externally the injured 
artery." Aneurisms formed in this way are not unusual in the extre- 
mities, more especially at the flexures of the joints ; and they are more 
frequent in men than in women, probably because the exciting causes 
of their formation are such as the former are more exposed to than the 
latter. In most instances, the rupture of the coats is attended with 
sharp pain, and many patients have stated, that they felt as if they had 
received a smart blow on the part, and have been able from this circum- 
stance to date the commencement of the disease. Rupture does not 
appear ever to take place in a sound artery, and if it did, the experi- 
ments of Jones prove that it would not be followed by an aneurism, as 
an effusion of lymph takes place, by which the vessel is strengthened at 
the injured part. 

3. By Dilatation and Rupture. — Cases recorded by Lancisi, Friend, 
Guatteni, Morgagni, Monro, and many subsequent observers, leave no 
doubt that aneurism may arise from dilatation and rupture conjointly ; 
and in the opinion of many distinguished pathologists, this is the most 
frequent mode of its formation. There is first a dilatation of all the 
coats, forming a true aneurism ; but when the expansion reaches a cer- 
tain point, the inner and middle coats, having less power of extension 
than the outer, become ruptured or give way, either after or without 
previous ulceration ; and the outer coat becomes distended and forms a 
sac which surmounts the primary dilatation. The expansion of all the 
coats constitutes a true aneurism, which may be termed primary ; the 
dilatation of the outer coat forms a consecutive aneurism. Such cases 
have been denominated compound or mixed aneurisms. The peculiarity 
of this mode of formation is, that rupture or ulceration of the internal 
and middle coats takes place after their dilatation, and is followed by a 
still farther dilatation of the outer coat. Examples of this form of 
aneurism occur not unfrequently in the aorta. The above are the prin- 
cipal changes in the coats of arteries constituting aneurisms ; and they 
may all be said to proceed from pre-existing changes connected with the 
cartilaginous steatomatous or calcareous degenerations, or with these 
conjointly ; or the pre-existing change may, in some instances, consist 
only of a low grade of inflammation causing debility and defective vital 



ANEURISM. 413 

cohesion of texture, — common results of inflammation in many other 
textures of the body. There can be no doubt, however, that the steato- 
matous degeneration is by far the most frequent predisposing cause of 
aneurism, and the rationale of its operation may be very easily under- 
stood from what was stated, in a former section, as to the conditions to 
which it gives rise. If the degeneration be confined to a particular 
part, and implicate only one side of an artery, it is easy to conceive 
how, on the destruction of the elasticity of the inner and middle coats, 
the column of blood acting with equal force on every side will give rise 
to a dilatation or pouch on one side, constituting a sacciform aneurism. 
If the degeneration extend around the whole circumference, and be 
abrupt at its commencement and termination, the distending force may 
cause a cylindrical aneurism ; whereas, if the transition from the healthy 
to the diseased state be more gradual, a fusiform aneurism will more 
probably be the result. As has been already stated, any of the various 
degenerations of the coats, or a low grade of inflammation may consti- 
tute the pre-existing change which predisposes to the formation of aneu- 
rism. The steatomatous degeneration is by far the most frequent, the 
true calcareous degeneration of old people comparatively rare. The 
latter, however, may lead to the formation of aneurism by causing rup- 
ture or ulceration of the inner coats, or the narrowing of the arterial 
canal, which it occasions, may be followed by dilatation on its cardiac 
side, leading to the giving way of the inner and middle coats. 

The three modes of formation, then, are — by dilatation alone, by 
rupture alone, or by dilatation and rupture conjointly. 

III. Varieties. — Besides the differences of form which have led to the 
appellation of sacciform, fusiform, cylindrical, and varicose, and the 
differences in the kind of degeneration which may constitute the pre- 
existing change, true aneurisms (using that expression in the sense 
already affixed to it) present numerous varieties in the condition of the 
several coats of the artery and their relation to the aneurismal sac. 

The principal varieties are the following, the first four of which are 
illustrated by Wardrop, by the accompanying diagrams. 

First diagram. 1st. The parietes of the aneurismal sac 

/^\ ma y ^ e f° rme d by the distension of the 

'r\^ — three coats. 

Second diagram. 2d. They may be formed by the dilata- 

/C^\ tion of the internal and external coats, 

=t \ the middle coat having been ruptured. 

Third diagram. 3d. They may be formed by the dila- 

/n tation of the external coat, the middle 

■ — and internal coats having been ruptured 

or destroyed by ulceration, or by rup- 
ture and ulceration. 
Fourth diagram. 4th. They may be formed by the dila- 

tation, or hernia, of the internal coat, 
~ the external and middle coats having 
given way. 
This rare variety, examples of which have been observed by Haller, 



414 ANEURISM. 

Dupuytren, Dubois, Breschet, Laennec, and Liston, lias been hitherto 
regarded by most observers as peculiar to the aorta, the inner membrane 
of which is more loose and elastic than that of other parts of the arte- 
rial system ; but Breschet conceives that he has proved its occurrence 
in smaller arteries. It probably arises from the destruction of the ex- 
ternal and middle coats by disease, and according to Laennec, the inner 
coat will protrude and form an aneurismal sac while the swelling is 
small, but will be apt to burst, as the tumour becomes larger. Laennec 
refers to four examples, in two of which the aneurisms were of the size 
of cherries, and the inner membrane, though dilated, was entire ; in the 
other two, they were of the size of walnuts, and the inner coat had given 
way. Laennec says — " The opinion at present current in the Parisian 
schools, viz., that in aneurism the internal coat remains entire, and 
protrudes in the form of a hernia, through the ruptured fibrinous tunic, 
is more untenable as a general position than that of Scarpa, who main- 
tains the rupture of the two internal tunics in every case of the disease. 
Both these opinions are 'true in certain cases, but not in all." John 
Hunter, Scarpa, and Sir Everard Home, removed the external and 
middle coats of arteries in various experiments on living animals, with 
the view of ascertaining whether the force of the circulating current 
would dilate the inner coat into an aneurism ; but they found that in- 
stead of an aneurism resulting, effusion of lymph took place, and the 
part healed without any change of size in the channel of the artery. 

5th. The dissecting is a very rare variety. Laennec has given an 
account of one example, and Mr. Guthrie of two. In the case men- 
tioned by Laennec, the aneurism was very extensive ; yet the person 
was not suspected, during life, of having any disease of the vascular 
system. The aneurism extended from the arch of the aorta to its 
division into the common iliacs, and is the largest example of this variety 
on record ; — " The internal and middle coats had been divided by a nar- 
row transverse fissure, extending over two-thirds of the circumference 
of the artery ; and the blood, instead of extending the external coat into 
a sac, had insinuated itself between it and the middle fibrous coat, and 
dissected them from each other, through more than half the circum- 
ference of the artery, from the arch of the aorta down to the common 
iliacs." Here the aneurismal sac was formed on one side by the ex- 
ternal coat, and on the other by the middle and internal coats. In one 
of the cases recorded by Mr. Guthrie, there was a fissure about half an 
inch in extent, by which the blood escaped through the inner and 
middle coats, and effected a separation of the middle and external coats, 
so as to form a pouch about six inches in length in the anterior part of 
the descending aorta. In the other example mentioned by Mr. Guthrie, 
the inner and middle coats' of the aorta were divided along half the cir- 
cumference by a very clean rent, situated opposite to the origin of the 
arteria innominata, and the separation of the external and middle coats 
extended on the one side from the rent to the origin of the aorta, and 
on the other to a point opposite to the origin of the left subclavian. 
Laennec was the first writer who gave a minute description of this 
curious variety, and it has been carefully investigated by llokitansky, 



ANEURISM. 415 

who gives an account of eight cases which came under his own observation. 
These eight, together with two others, also referred to by Rokitansky 
(viz. the one described by Laennec, and one by Dr. Stosch), the two 
described by Guthrie, two by Mr. Smith, one by Nivet, and two by 
Goddard and Pennock, being seventeen in all, were, until lately, so far 
as I know, the only recorded examples of this kind of aneurism. In 
almost all these examples the heart was diseased, and more especially 
its left side ; in some instances there was dilatation with hypertrophy ; 
in others dilatation with attenuation ; and in many of them there were 
evident signs of steatomatous and calcareous deposits. According to 
Rokitansky, it sometimes commences by disease of the middle and 
internal coats, in which case the continuity of these coats is destroyed, 
and the separation of the external coat follows as a later effect ; in other 
instances, it is the consequence of chronic inflammation of the external 
coat, which gives rise to separation of that coat, followed by rupture of 
the middle and internal coats. In the one set of cases he considers 
that the rupture precedes, in the other, that it follows, the separation. 

6th. The late Mr. Shakelton described a kind of aneurism previously 
unnoticed, in which the blood had forced its way through the internal 
and middle coats, dissected the middle from the external coat to the 
extent of four inches, and then burst again into the channel of the ar- 
tery, thus forming a new channel, which eventually superseded the old 
one, — the latter having been obliterated by the pressure of the tumour. 
In this case the aneurismal sac was formed by five coats on the one side, 
and the external coat on the other. 

7th. In the body of a man about fifty years of age, who had not 
been supposed to be the subject of any disease, and who died very 
suddenly before any medical man had an opportunity of seeing him, I 
met with a singular variety of dissecting aneurism. In the arch of the 
aorta, about three-fourths of an inch to the left side of the origin of the 
left subclavian artery, there was a rent of the inner and middle coats ; 
from this rent to near the origin of the aorta on the cardiac side, and 
for upwards of an inch on the capillary side the external coat was sepa- 
rated from the middle, round nearly two-thirds of the circumference of 
the artery. There was an opening upwards of half an inch in diameter, 
by which the aneurism thus formed burst into the pulmonary artery, a 
little below the place where that vessel gives off its two branches. The 
aorta was affected with steatomatous deposit in many places, and in this 
case there were, beyond all doubt, patches of the same kind of degene- 
ration in the pulmonary artery. There was very slight hypertrophy of 
the left side of the heart. 

A true aneurism is invariably limited at first ; that is, it is confined 
within a proper cyst ; but, by rupture or ulceration, the cyst may give 
way, and the blood become diffused through the surrounding textures ; 
in which case the aneurism is said to be diffuse. 

IV. Contents of the Sac. — The contents of an aneurismal -sac are not 
the same at all periods ; they vary considerably, according to the length 
of time that has elapsed since the commencement of the disease. At 
first the sac contains only fluid blood, and in this stage, by exerting 



416 



ANEURIS 




pressure on the swelling, or on the artery leading to it, the aneurismal 
sac is readily emptied. In the next stage the contents consist partly of 

fluid blood, and partly of a solid 
Fi g- 136 - substance, the nature of which will 

be afterwards described, bearing 
but a small proportion to the fluid. 
In a yet more advanced stage, the 
sac still contains both fluid blood 
and coagulum ; but the proportion 
of the latter to the former is greatly 
increased. When after death an 
opportunity is afforded of examining 
an aneurism of some standing, the 
sac is found to contain what is 
technically called the coagulum, 
consisting of two parts, namely, 
blood more or less firmly coagulated, 
the coagulation having probably 
taken place subsequent to death, 
and a lamellated fibrinous concre- 
tion. This fibrinous concretion is 
found to consist of numerous con- 
centric laminae, varying in firmness 
according to their situation ; those 
nearest to the blood having usually a soft and somewhat reddish ap- 
pearance ; those farther removed being more dry, more pale, and more 
adherent ; and the external ones in contact with the sac, having a very 
opaque, dry appearance, and being of a somewhat friable consistence. 

A most important change which takes place soon after the occurrence 
of aneurism, is the commencement of the formation of the fibrinous con- 
cretion. The blood, after the formation of the aneurism, leaves upon 
the internal surface of the sac a layer of coagulum, and this being fol- 
lowed by successive depositions of fibrin, the lamellated concretion is 
gradually formed. If the form of the sac be such as to admit of the re- 
tardation of the current of circulation in it, as in a sacculated aneurism, 
haviug a narrow communication with the arterial trunk, the coagulum 
is formed much more readily : and this explains a most important dif- 
ference in the pathological conditions of an aneurism, and a simple dila- 
tation of the artery ; for in the latter, where the surface is smooth, and 
no retardation of the current of blood can take place, there is no fibri- 
nous concretion, and consequently no means of protection for the weak- 
ened part. 

V. The various ways in which Aneurisms prove fatal. — 1. Aneurisms 
frequently prove fatal by making their way to the surface of the body, 
or to the mucous canals, or to the serous cavities. When an aneurismal 
tumour reaches the surface of the body, it never bursts by laceration, 

Fig. 136. Farther growth of aneurism prevented by coagulum becoming adherent to 
the artery around the opening of the sac. From Hodgson. 






ANEURISM. 



417 



integument sloughs, and on the separation of the 



Fis. 131 




but the attenuated 
slough, an escape of blood 
takes place. The flow of 
blood is for a time arrested 
by a part of the coagulum 
forming a plug, but by and 
by, the hemorrhage returns, 
and the patient sinks in 
consequence of repeated at- 
tacks of it. The process is 
the same when the disease 
opens into the mucous ca- 
nals, or into an organ lined 
with a mucous membrane, 
as the oesophagus, intes- 
tines, or bladder. The part 
does not give way by lacera- 
tion, but after being attenu- 
ated by absorption, it is destroyed by sloughing. I have a preparation 
of an aneurism of the aorta, in which an opening was made into the 
trachea by the process above referred to, and the first discharge of blood 
caused death by suffocation. 

Aneurisms frequently prove fatal by bursting into some of the serous 
cavities, as the cavities of the pleurae, that on the left side more fre- 
quently than that on the right, the peritoneum, the serous cavity of the 
tunica arachnoidea, or the pericar- 
dium. Of the last, examples were 
seen by Morgagni, Sir Astley Cooper, 
and others ; and I have a beautiful 
specimen taken from a man who died 
suddenly, in whose pericardium I 
found a large quantity of blood, the 
fatal rent being about an inch in 
length. In the two former modes 
of fatal termination, the integument, 
or mucous membrane, after being 
attenuated by absorption, gives way 
by sloughing ; in the last the serous 
membrane gives way by a rent. In 
the third mode, and sometimes in the 
second, death results from a single 
discharge of blood ; but in the first, 
from repeated hemorrhages. 

2. Death may be caused by pres- 
sure on important parts, as the tra- 
chea, the bronchial tubes, the lungs, the oesophagus, the thoracic duct, 



138. 




Fig. 137. Aneurism of arteria innominata, which proved fatal by bursting into the 
trachea. From a preparation in my own museum. 

Fig 138. Aneurism of the aorta, which induced caries of the vertebras, and fatal 
compression of the spinal cord. From a preparation in my museum. 

27 



418 



ANEURISM. 



of which Laennec witnessed an example, or the spinal cord. I have 
several specimens of aneurisms which proved fatal by pressure on the 
spinal cord; in one of them the bodies of two vertebrae, and in another 
those of three, are entirely absorbed on the left side of the spine. 

3. By constitutional irritation, the system sympathizing with the 
local irritation. This will be most likely to occur when the aneurism is 
surrounded by unyielding textures, which are capable of offering con- 
siderable opposition to its integument. 

4. Aneurisms may prove fatal in consequence of inflammation at- 
tacking the sac and surrounding parts, and giving rise to suppuration 
and the formation of large abscesses. This is by no means a frequent 
occurrence, but various examples are on record. 

5. Death may ensue from the bursting of the aneurism, and the escape 
of blood into the surrounding textures, that is, from a circumscribed 
aneurism becoming diffuse. The extravasated blood may so greatly 
interrupt the circulation as to cause gangrene, or the infiltration may 
be followed by unhealthy inflammation of the tissues, which are weak- 
ened by the pressure of the infiltrated blood, and death may be caused 
by the symptomatic fever, which in such cases usually assumes a typhoid 
type. 

Such are the most frequent modes of fatal termination of aneurisms ; 
there are others which, though of extremely rare occurrence, are occa- 
sionally met with. In an individual not suspected of labouring under 



Fig. W 



Fig. 140. 





any disease, who died instantaneously one morning, while rising out of 
bed, and whose body I was requested to examine, death was caused by 
an aneurism of the aorta bursting into the right auricle of the heart. 
This mode of fatal termination has also been seen by others. I have 



Fig. 139. Front view of aneurism of aorta. From a preparation in my museum. 

Fig. 140. Back view of same preparation, showing the aneurism, producing absorp- 
tion of the ribs, and making its way to the surface. Death was caused by part of the 
coagulum falling into the artery. 



ANEURISM. 



419 



lie. 141. 



in my possession a specimen taken from a case in which death was 
caused by an aneurism of the aorta making its way into the pulmonary 
artery. In some instances of aneurism of the aorta, it has been found 
on dissection, that fatal destruction of the circulation resulted from a 
portion of the coagulum falling from the sac into the artery. 

VI. Symptoms. — Sir Astley Cooper says, " With respect to external 
aneurisms, the symptoms may be divided into three stages. When you 
have an opportunity of seeing aneurism in its early stage, you will find a 
small tumour pulsating very strongly — much more strongly than in any 
subsequent stages ; for it may be taken as a general rule that the force 
of the pulsation is in the inverse proportion of the size of the aneurism. 
When an aneurism is first formed, it contains only fluid of blood ; and 
if you apply your finger to the artery between the 
aneurism and the heart, you will readily empty 
the aneurismal bag. In this state there is scarcely 
any pain, and no other alteration in the limb than 
some irregularity of circulation producing spasm 
in the muscles ; and when the patient is going to 
rest, cramps in the legs and sudden twitchings, 
w T hich prevent him from sleeping. The next state 
in which we find aneurism is when the blood is 
beginning to coagulate in the interior of the sac, 
the coats of which are very considerably thickened. 
At this time, if you press on the artery, you may 
empty the sac in part ; you will see the swelling 
reproduced when you take off the pressure. You 
cannot completely empty the bag by pressure, for 
a considerable degree of swelling will still remain. 
There is some degree of pain in the limb below in 
this stage of the disease, in consequence of the 
size of the swelling, and the pressure on the sur- 
rounding parts. The aneurism becomes a solid 
swelling, instead of a mere bag containing fluid 
blood, and the circulation is retarded by the pres- 
sure on the surrounding parts. In the next stage, the aneurism has 
acquired considerable magnitude, and the pulsation is, in a great degree, 
lost. Pulsation may be observed in some one part opposite to the 
opening from the artery, but it is seldom perceived over the whole 
swelling. A small portion of the blood still continues in a fluid state, 
but the greater part of it is filled with coagulum." 

The principal symptoms of external circumscribed aneurism are a 
swelling, pulsation synchronous with the heart's action, and at each pulsa- 
tion an elevation of the tumour, a heaving or uniform enlargement, a 
peculiar thrill felt on applying the hand, and a sound like that of bel- 
lows perceptible on applying the ear. For the purpose of diagnosis, it 
is of the utmost importance that the characteristic peculiarities of these 
symptoms should be clearly understood. 

1. The sivelling at first is small, but its increase is gradual ; " seldom 
so rapid as the outward bulging of an abscess ; seldom so tardy as the 
enlargement of any tumour not malignant." In the first stage it is 




420 ANEURISM. 

soft, and may be reduced by pressing the tumour or the artery leading 
to it ; in the second stage it is a little harder and less compressible ; 
and in the third stage it is still harder, and very slightly, if at all, 
susceptible of diminution by pressure. To whatever extent the tumour 
may be compressible, it immediately returns to its former size on the 
discontinuance of the pressure. By pressure on the trunk, leading from 
the aneurism, the tumour is increased. 

2. The pulsation is synchronous with the action of the heart, and is 
much more perceptible, both to the touch and the sight, in the first than 
in any subsequent stage. In the second stage the pulsation, in conse- 
quence of the deposition of fibrin, may be less distinct in certain parts 
of the tumour than in others ; hence it is said not to be " equal in all 
directions." In the third stage the pulsation is still further diminished, 
and may be limited to certain parts ; and it is scarcely, or not at all, 
perceptible if the sac be nearly filled with lamellated fibrin. The absence 
of pulsation, therefore, is no certain proof that a tumour is not an aneu- 
rism ; nor is the presence of pulsation any proof that it is ; for a tumour 
or an abscess may have pulsation communicated to it by its being 
situated over an arterial trunk, and in the case of an abscess so situated, 
the fluid nature of its contents renders the pulsation very deceptive. It 
will assist in diagnosis to remember, that the pulsation of an aneurism 
cannot be changed by any alteration in the position of the limb ; but 
that the pulsation communicated to a tumour in the neighbourhood of an 
artery, may be diminished or suspended by placing the limb in such a 
position as may remove the tumour from the artery, or by lifting the 
tumour off the artery, or pressing it aside. 

3. Elevation of the aneurism is perceptible, and is always synchro- 
nous with the pulsation. 

4. A heaving, or uniform enlargement, or distinct expansion at every 
point, simultaneous also with the pulsation, is quite diagnostic of aneu- 
rism. The impression communicated to the fingers of the examiner is, 
that the expansion is caused by the injection of a fluid into the cavity. 
This symptom differs very much from the pulsation or change of place 
of a tumour occasioned by an impulse from a neighbouring artery. The 
presence or absence of this symptom should be minutely inquired into, 
in the examination of every swelling supposed to be aneurismal. 

5. The peculiar thrill or rasping sensation, felt on placing the fingers 
over the aneurism, is supposed to be produced by the blood rushing 
over a rough surface. 

6. The sound, like that of a bellows (bruit de soufflet), is discoverable 
either by mediate or immediate auscultation. This sound, however, is 
no certain proof of the existence of aneurism, as it is well known that it 
may be produced by a tumour diminishing the calibre of an artery ; it 
may be made perceptible by compressing an artery with the stetho- 
scope, more especially if the individual be in a state of nervous agita- 
tion ; and it has often been perceived where, on dissection, no lesion of 
the coats of the arteries could be discovered. 

Of all the symptoms, the uniform expansion simultaneous with pulsa- 
tion, is the most unequivocal. The history of the symptoms often 
affords valuable assistance in making out the diagnosis in difficult cases. 



ANEURISM. 



421 



Fig. 142. 



The following symptoms, though not distinctive characters, usually in 
a greater or less degree attend aneurism at some period of the disease. 

Pain. — If an aneurism arise from dilatation, there is usually no pain 
at the period of its formation ; if there be first dilatation and then 
rupture, the pain is trivial ; but if the aneurism originate in rupture, 
sharp pain is felt at the formation of the disease ; and in all cases there 
is ultimately more or less pain or uneasiness, when the swelling attains 
great size in an advanced period of the disease. 

(Edema of the extremity, weakness, numbness, spasmodic twitchings, 
and sensations from compression or stretching of surrounding structures, 
are symptoms of frequent occurrence. If an aneurism be in the neigh- 
bourhood of a joint, it usually interferes to a considerable extent with 
the motion of the articulation. 

VII. Spontaneous Care. — Nature sometimes, though very rarely, 
effects a cure ; and an aneurism, therefore, which is not accessible to 
surgical treatment, does not invariably terminate fatally. The processes 
by which a spontaneous cure may be effected are the following : — 

First. — The most frequent manner of a spontaneous cure is, by the 
sac becoming filled with lamellatecl coagulum. The various stages of 
this mode of favourable termination, first minutely described by Hodg- 
son, and afterwards minutely investigated 
by many other competent observers, are 
the following : — the sac becomes com- 
pletely filled so as to preclude all further 
entrance of blood. The artery, by depo- 
sition of coagulum, becomes impervious 
as far as its nearest considerable branches, 
and is ultimately converted into a small 
impervious cord, — the circulation in such 
cases being maintained by the blood, 
which is received into the branches given 
off from the arterial trunk above the 
aneurism, being discharged into branches 
given off from the trunks below, and 
conveyed through the last-mentioned 
branches by inverted circulation into the 
trunks from which they originate — both 
sets of branches becoming much en- 
larged. Or the artery may remain per- 
vious, the blood passing over the closed- 
up sac at the part where its mouth 
communicated with the vessel. The tu- 
mour becomes smaller and harder in consequence of absorption. Petit 
records a case of spontaneous cure, in which the aneurism, at one time 
as large as an appje, became as small as an olive. Examples of this 
mode of spontaneous cure are to be found in the writings of most sur- 

Fig. 142. Spontaneous cure of aneurism of the femoral artery by the sac being 
filled with coagulum ; the vessel remaining pervious. From a preparation in my 
museum. 




.99 



ANEURISM. 



gical authorities on this subject. The accompanying drawing is taken 
from a very good example in my own collection of preparations. 

Second. — In some examples where the whole circumference of a vessel 
has become aneurismal, a spontaneous cure has been effected by a canal 
being left through the centre of the lamellated coagulum, through which 
the blood continued to circulate. There is reason to believe this to be 
an extremely rare mode of spontaneous cure. 

Third. — It occasionally happens that from over-distension, or some 
other circumstance, inflammation of the sac and surrounding parts 
supervenes, and goes on to gangrene, the whole of the aneurismal tumour 
sloughing away, and by that means a spontaneous cure is effected ; — 
hemorrhage from the vessels leading to the part being prevented by the 
same process as when gangrene takes place in other circumstances. 

Fourth. — Another mode is by the aneurism pressing on the trunk 
leading to or from the aneurism, so as to obstruct the circulation. If 
the size and position of the tumour be such as to cause an approxima- 
tion of the opposite sides of the artery either on the cardiac or capillary 
side, there can be no doubt that a cure will be the result. When the 
pressure is on the cardiac side, the cure is effected on the same prin- 
ciple as in one of the modes of surgical treatment described in the next 
section. 

Fifth. — Pressure on the trunk leading to the aneurism may be pro- 
duced by other causes than the aneurism itself, as by a tumour not 
aneurismal, or by another aneurism on a neighbouring artery ; and thus 
a spontaneous cure may result. Mr. Liston records an example of sub- 
clavian aneurism, which on dissection was found to have been cured by 
an aneurism of the arteria innominata. 

Sixth. — The same favourable result will follow, when inflammation 
takes place in the artery, and fills its calibre with coagulum. 

Seventh. — Sometimes a portion of lamellated fibrinous coagulum be- 
coming detached falls into the sac, and thus causes diminution, or com- 
plete occlusion of the mouth. In the latter case, coagulation of the 
blood in the sac must take place, and in the former the consequent 
diminution of the circulation through the sac is much calculated to 
promote deposition of fibrin, and to accomplish a spontaneous cure. In 
this mode the artery may or may not become impervious. 

Eighth. — A portion of the coagulum may fall into the artery and 
obstruct it, thus effecting a cure. Or, 

Ninth. — The aneurism may burst and become diffuse. If the presence 
of the diffusely infiltrated blood do not give rise to the untoward conse- 
quences formerly described, it may, by its pressure on the cardiac side 
of the tumour, so weaken the force of the circulation through the aneu- 
rism, as to promote the deposition of lamellated coagulum, or to arrest 
the circulation of the fluid parts of the contents of the sac, and thus 
promote their coagulation. Such are the methods by which nature 
sometimes, though rarely, effects a spontaneous cure ; and it may be a 
consolation to patients who are subjects of aneurisms in inaccessible 
situations to know that their case is not hopeless, and that a sponta- 
neous cure is not impossible. 

VIII. Treatment. — As the enlargement and ultimate giving way of 



ANEURISM. 423 

an aneurism depend on the force with which the current of blood is sent 
into the sac, leading principles in the treatment have been, to diminish 
this force, or to arrest the current altogether. By fulfilling the first 
indication, the progress of the disease must be retarded, and its cure 
may be effected, as the diminution in the velocity and force of circula- 
tion promotes the formation of lamellated coagulum ; by the second in- 
dication, a cure is effected, for the fluid contents of the sac being set at 
rest become coagulated. Consolidation induced by coagulation, or by 
deposition of fibrin, or by both, will be followed by increased hardness, 
diminution by absorption, and the other favourable symptoms mentioned 
in the description given of the first mode of spontaneous cure. 

The medical treatment, which is the only treatment practicable when 
the aneurism is in the cavities, or in situations inaccessible to the sur- 
geon, is useful on the principle already stated, that the diminution of 
the force and velocity of the circulating current increases the tendency 
to deposition of coagulum. This diminution is effected by lessening the 
vigour of the heart's action and the quantity of t\ie circulating fluid. 
For the attainment of these objects, the vigorous employment of anti- 
phlogistic treatment, to as great a degree as is compatible with the con- 
tinuance of life, was originally proposed and practised by Albertini and 
Valsalva. It is designated their treatment of aneurism, and from their 
experience and that of others it acquired great celebrity, which, how- 
ever, it has not maintained. Albertini and Valsalva reduced their 
patients, by repeated abstractions of blood, to such an extreme degree 
of debility, that they could scarcely raise their arms from bed ; they 
enjoined the most perfect quietude both of body and mind ; they directed 
that their patients should be kept constantly in the horizontal posture 
in bed, and that their diet should be of the most unstimulating kind ; 
and they gradually reduced the quantity to half a pound of pudding in 
the morning, and a quarter of a pound in the evening, forbidding every- 
thing else except a limited quantity of water. When this treatment 
effected a cure, it was by favouring the deposition of lamellated fibrin- 
ous coagulum. Its efficiency in arresting the progress of internal aneu- 
rism and accomplishing its cure, has been proved by the experience of 
Albertini, Valsalva, Pelletan, and other observers ; but there is reason 
to believe that its effects have been very much overrated. Be that, 
however, as it may, few persons will submit to its employment to the 
extent practised by Albertini and Valsalva ; and there can be no doubt 
that it has often been used to a hurtful extent, and that in some persons 
it is not free from the danger of proving fatal by inducing other dis- 
eases. Its employment is, therefore, often inadmissible. For these 
reasons, it is not now adopted in the vigorous manner practised by 
Albertini and Valsalva, nor with a curative view, but in a very modified 
form, and with little hope of doing more than checking the progress of 
the disease. By medical treatment alone, can the progress of aneurisms 
in inaccessible situations be retarded ; and of the necessity of employing 
all judicious means for diminishing the circulation, and of endeavouring 
to preserve the body in a quiescent state there can be no reasonable 
doubt. Although it may not be prudent to reduce the patient to a 
state of great debility, there can be no question that it is advisable and 



424 ANEURISM. 

necessary in every case of internal aneurism to enjoin quiet, restriction 
of diet, abstinence from animal food, and from all stimulants ; to caution 
patients that they guard against all emotions of mind, and refrain from 
every kind of exercise by which the circulation could be accelerated ; 
and occasionally to have recourse to bleeding, proportioned in frequency 
and quantity to the force of the circulation, and the strength of the 
patient. A precaution which ought always to be observed is, to with- 
draw the blood slowly from the patient placed in the horizontal position, 
and never to take away a large quantity at once, lest syncope should be 
induced, which in internal aneurism, more especially if there be disease 
of the heart, is attended with the greatest danger. Digitalis, from its 
effect of weakening the action of the heart, has often been administered ; 
but its employment is a matter of very questionable propriety, as the 
extent to which it affects the heart's action cannot be regulated with 
certainty, and its decided influence is hazardous in such cases. The 
superacetate of lead has long been used in Germany in cases of internal 
aneurism ; and Laennec, Dupuytren, and Bertin in France, and some 
practitioners in this country, state that they consider it to have been 
used with advantage. 

Surgical Treatment. — Until John Hunter, in 1785, proposed and 
practised his operation for the cure of aneurism, the treatment adopted 
was either amputation, or the employment of pressure, or the perfor- 
mance of some one or other of the following operations. 

One of the earliest operations we read of is that which was practised 
in the time of Celsus, who lived in the beginning of the first century of 
Christianity, and was the most elegant writer on medicine and surgery 
among the Romans. In those clays the practice was to open the tu- 
mour, to clear out its contents, and to endeavour to stop the hemor- 
rhage by thrusting the actual cautery into the wound — a procedure 
almost invariably fatal, and it would have been very surprising if it had 
been otherwise. 

Another operation is that which was practised by Rufus the Ephe- 
sian, a zealous surgeon who flourished in the beginning of the second 
century in the time of the Emperor Trajan. He first by means of a 
ligature secured the artery immediately above the aneurism, and then 
cut into the tumour and removed its contents. 

Antyllus, who is generally believed to have flourished in the begin- 
ning of the fourth century, followed the example of Rufus in cutting 
into the aneurismal swelling, and removing its contents ; but he previ- 
ously tied the artery below, as well as above the swelling, and endea- 
voured to heal the wound by granulation. 

Such were the operations practised among the Romans. 

The Greek and Arabian writers recommended an operation in some 
measure different from those practised among the Romans, and, in one 
particular, bearing a resemblance to that in use at the present day. 

Aetius, a native of Amida, and a pupil of the celebrated School of 
Alexandria, who flourished in the middle of the sixth century, and the 
celebrated Paulus iEgineta, also a pupil of the Alexandrian School, who 
lived about the middle of the seventh century, both practised the same 
operation. Aetius recommended for the cure of aneurism at the bend 



ANEURISM. 425 

of the arm, to include the brachial artery in a ligature a little below the 
axilla, and then to evacuate the contents of the aneurism : the peculi- 
arity of this method was the application of the ligature at a considerable 
distance from the aneurism. Paulus iEgineta not only practised this 
operation for the cure of aneurism at the bend of the arm ; but adopted 
it also in aneurisms in various other situations. 

Such was the practice recommended by the Greek writers. 

These operations were succeeded by one still more formidable and 
dangerous, which consisted in opening the aneurismal sac, clearing out 
its contents, then searching for the artery and securing it by a ligature, 
both above and below, at its openings into the sac. This horrible and 
dangerous procedure was always attended with extreme pain and irri- 
tation, and was for the most part fatal, as might have been anticipated, 
considering the many hazards which the patient had to encounter. 

Another operation, practised by Guattani and others, consisted in 
laying open the sac, removing its contents, and applying graduated 
compresses to the extremity of the artery at the mouth of the sac. In 
performing this operation, some surgeons, among whom was Guattani, 
endeavoured to arrest the hemorrhage by pressure alone, using com- 
presses for this purpose ; others, retaining the use of compresses, also 
applied styptics. After the introduction of the torniquet by Morel, 
towards the end of the seventeenth century, the danger from loss of 
blood during the operation was diminished, as hemorrhage could be 
prevented until the surgeon had accomplished the immediate object of 
his operation. Whoever reads the description of their operations, as 
given by Guattani, Deschamps, Pelletan, and others, will readily admit 
that few things in the history of surgery are more horrible, and that it 
is not, therefore, very surprising that many surgeons in those days 
arrived at the conclusion, that until a safer and more successful mode of 
operation should be discovered, the most advisable procedure was ampu- 
tation, which, accordingly, was often resorted to. 

Another operation was, however, before long, suggested, namely — 
the method so successfully practised at the present day, of tying ar- 
teries. It seems very surprising that there has been so much difference 
of opinion as to whether this operation should bear the name of An el, 
of Desault, or of Hunter, when, by a careful examination of the then 
practice, it is so easy to determine the merit which belongs to each of 
these great men. 

To Anel, undoubtedly, the merit belongs of having first introduced 
the important principle of not interfering with the aneurismal sac, but 
leaving it entire ; he tied the artery above the sac, but as close to it as 
possible. This method he successfully practised on the brachial artery 
in 1713 ; the important point in it is the placing of the ligature on the 
artery, and not interfering with the tumour. 

The treatment which was practised by Anel for an aneurism of the 
brachial artery, Desault applied to a case of aneurism of the popliteal 
artery in the Hotel Dieu, Paris, in the month of June, 1785 — the same 
year in which Hunter performed his first operation. The grand objec- 
tion to the method practised by Anel and Desault is, that the artery 
was tied as close as possible to the aneurismal sac ; its recommendation 



426 A NB UK ISM. 

(as has been already observed) is, its principle of not interfering with 
the tumour. 

To John Hunter, undoubtedly, belongs the merit of suggesting the 
method now so generally adopted, and of establishing its success by 
experience. In Hunter's method, to which he was led by a considera- 
tion of the physiological principles applicable to the cure of this disease, 
the aneurismal sac is not interfered with, and the artery is tied on the 
cardiac side of the tumour, at a considerable distance from it, where the 
artery is easily accessible, and where its coats are more likely to be free 
from disease, the removal of the aneurism being left to the action of the 
absorbents. Hunter performed his first operation in St. George's Hos- 
pital, London, in December 1785 (a few months after Desault's operation 
in the Hotel Dieu, Paris), in a case of popliteal aneurism, for the cure 
of which he tied the femoral artery ; and the desired result was ob- 
tained. This mode of operation is justly regarded as one of the greatest 
improvements in surgery, nor can there be any question that Hunter is 
entitled to the praise of having first suggested it and proved its success. 
It has been said " that those w r ho render themselves useful to their 
fellow-men by their important discoveries in the sciences belong to 
every country, and, that they deserve praise from one pole to the other ; 
but it seems to us, also, that each nation may, without being taxed with 
egotism, claim for itself, and attach to its own soil the discoveries or 
improvements which are its property, and which tend to increase its 
scientific glory." 

As the effects of a ligature properly applied to an artery, and the 
various changes which result, have already been minutely described in 
a former section, it seems unnecessary to do more than to refer to that 
description, and to add, that the immediate object which the surgeon 
wishes to accomplish is, to set the fluid contents of the sac in some 
measure at rest, which will be indicated by the arrest of the pulsation 
and the bruit ; and this will be followed by their coagulation, and, con- 
sequently, by the entire consolidation of the tumour. Slight contrac- 
tion of the sac takes place at the moment the force of the blood is 
arrested by the application of the ligature, and the whole contents of 
the sac being converted into coagulum, the remaining part of the cure 
is carried on by the same process as when consolidation takes place in 
a spontaneous cure. From what has been stated as to the immediate 
object which the surgeon desires to accomplish, it will be evident, that 
it must always be a matter of the greatest anxiety that the pulsation be 
arrested on the application of the ligature ; and, as the desired result 
may be prevented either by the existence of a variety of the arterial 
system, or by an extremely free communication with the trunk between 
the ligature and the aneurism by means of anastomosing vessels, the 
immediate effect produced by the ligature on the pulsation is anxiously 
observed. It often happens that, although the pulsation is arrested by 
the application of the ligature, yet in the course of a few hours, or at a 
later period, on the collateral circulation becoming fully established, it 
returns in a slight degree. This is, no doubt, occasioned by the blood 
not being rendered altogether stationary at once, and by some passing 
into the aneurismal sac from vessels arising above the ligature ; but, 



ANEURISM. 427 

although the return of pulsation even in any degree is always a cause 
of much anxiety to the surgeon, it almost invariably, in such cases, gra- 
dually diminishes and ultimately disappears, in consequence of the 
enfeebled force of the circulation being insufficient to overcome the ten- 
dency of the blood to coagulate. The condition which it is desired to 
produce by the operation is, the solidification of the tumour. For pro- 
moting that state, it seems essential that the force of the circulation be 
enfeebled, and this is accomplished by tying the main trunk, although 
the blood is not rendered at once perfectly stationary in the aneurismal 
sac. The tumour is gradually diminished by absorption ; and, with 
regard to the condition of the main trunk, on which the aneurism is 
situated, it has been found, in some instances, that it has become oblite- 
rated from the first branch above the ligature to the first below the 
aneurism, an example of which is mentioned by Sir Astley Cooper, 
where the obliteration extended from the origin of the deep femoral 
artery to the commencement of the tibial arteries. 

But such an extent of obliteration is extremely rare ; and in most 
specimens which have been examined and recorded, it has been found, 
that the trunk has been obliterated in two situations, namely, from the 
first branch above the ligature to the first branch below it, and for a 
short distance above and below the aneurism : so that an insulated por- 
tion of the artery preserves its cavity between the obstructed parts, and 
a double collateral circulation connected with the insulated portion, 
assists in maintaining the circulation through the extremity. By one 
collateral circulation blood is conveyed from the arterial trunk above 
the ligature, to the upper part of the insulated portion, and by the 
other, from the insulated portion to the main trunks on the distal side 
of the aneurism. At the time when Hunter performed his operation, 
the proper method of applying a ligature to an artery was not known, 
and to prevent hemorrhage, various plans were adopted which were cal- 
culated to insure the occurrence of the event they were intended to 
avert. Some of these methods were, the application of ligatures of 
reserve, tying the ligature very loosely from a dread of dividing too 
early the arterial coats, the application of pieces of tape for ligatures, 
and the introduction of soft bodies, such as pieces of cork, between the 
ligature and the artery. But the experiments and the investigations of 
Jones having discovered and established the principles which should be 
the guide in applying a ligature to an artery, the Hunterian operation 
has, by the application of these principles, been brought to its present 
state of perfection. The site selected for the operation should not be 
so near to the aneurism, as to interfere with the artery where its coats 
are the subject of degeneration, nor so distant from it as to risk the 
danger of too free a collateral circulation. The ligature should be 
small, round, and firm ; the artery should be exposed as little as possible 
in front, only so. far as to admit the point of the needle into contact 
with the artery ; and laterally and underneath, only by the track of the 
needle. The ligature should be tied very firmly, so as to divide the 
inner and middle coats ; one end of the ligature should be cut off, and 
means used to promote union of the wound by the first intention. For 
some time previous to the operation, as well as afterwards, until the 



428 ANEURISM. 

ligature comes away and the wound is perfectly healed, it is necessary 
to enjoin the use of the antiphlogistic regimen ; and in some cases, 
where the pulse is very strong, it is advisable before the operation, to 
have recourse to general depletion for the purpose of diminishing the 
force of the heart's action. With the same view it is also prudent, in 
some instances, to bleed after the operation ; and when an important 
vessel in the neck is tied, bleeding is sometimes to be recommended as 
a prudential measure to diminish the danger of the occurrence of con- 
gestion of the lungs. After the operation, the limb should be placed 
in a convenient position, the part where the vessel is situated being 
relaxed. The temperature of the limb usually falls a little, but it soon 
rises, and as the collateral circulation becomes established, it rises above 
the natural standard. While the temperature is below the natural 
standard, it is extremely injudicious to interfere in any way except by 
covering the limb with flannel, or some soft cloth ; for reaction speedily 
comes on without interference ; and there can be no doubt that in 
various instances where gangrene has followed, it has been the result of 
excessive reaction induced by the application of heat and stimulants 
during the depression which had been occasioned by the tying of the 
main trunk, and the consequent stoppage of the supply of blood. Until 
some time after the ligature has come away, it is necessary to enjoin 
not only that the body be kept in perfect rest, but also that the patient 
should guard against any mental emotion, or any circumstance by which 
the circulation might be accelerated. At no period is this more neces- 
sary than at the removal of the ligature. In some few instances, but 
it is an extremely rare occurrence, the temperature does not rise above 
the natural standard at any period after the operation ; the reason of 
which is supposed to be, that the collateral circulation had become fully 
established before the performance of the operation. From what has 
been stated it will be evident, that only one ligature should be used. 
The only exception to this rule is, when from any circumstance it hap- 
pens that at the part where the artery is to be tied, it is injudiciously 
detached from its surrounding relations ; in such a case it is prudent to 
apply two ligatures, one at each extremity of the detached portion — a 
practice as ancient as the time of Aetius, — and to divide the artery 
between them, or to leave it entire, as may seem advisable in the parti- 
cular circumstances of the case. 

Of late years, however, three operations have been practised; namely, 
that of Hunter, that of Brasdor, and that of Wardrop. 

From what has been stated, the nature and advantages of the Hun- 
terian operation are, I trust, evident. It consists, as has been already 
explained, in tying the aneurismal artery on the cardiac side of the 
tumour, and at some distance from it. 

Brasdor s operation consists in tying the trunk of the artery on the 
distal side of the aneurism, and in its near proximity. 

Wardrop 's operation consists in tying one of the two terminating 
branches of the artery on the distal side of the aneurism. 



ANEURISM. 



429 



These different modes of procedure have been illustrated by a diagram 
similar to the following : — 



Fig. 143. Fig. 144. 

Hunter's mode. Brasdor's mode. 



Fig. 145. 
Wardrop's mode. 





Brasdor suggested that his mode of operation might be applicable to 
some aneurisms so placed, as to render the Hunterian operation im- 
practicable. Desault also recommended this mode, but neither he nor 
Brasdor performed the operation. Their contemporary, Deschamp, 
was the first who performed the operation ; but it was under very un- 
favourable circumstances, and without success, in a case of aneurism 
as high upon the common femoral as Poupart's ligament. Sir Astley 
Cooper was the next who practised Brasdor' s method; it was in a case 
of aneurism of the external iliac ; the common femoral was tied, but 
the patient died of the bursting of the tumour some time afterwards. 
These are the only two instances on record, in which, during a period 
of more than forty years, Brasdor 's method was performed, and from 
their unfavourable results it fell into disrepute. To Wardrop belongs 
the merit of having first proved the success of Brasdor's operation. The 
subject of the operation was a female, seventy-five years of age, and the 
case was one of aneurism of the common carotid artery, where it was 
impracticable to tie the artery on the cardiac side of the tumour. He 
tied the carotid on the capillary side, and the result was successful. 
Wardrop performed this operation in 1825, and it has since been prac- 
tised by Bush and others, in cases of carotid aneurism, and the results 
have proved that although it is a mode of treatment obviously inferior to 
the Hunterian method, and not generally applicable, yet a surgeon is jus- 
tified in recommending it for certain aneurisms, situated so near the trunk 
as to render it impossible to tie the artery on the cardiac side of the tu- 
mour. It is obvious that the common carotid presents the most favour- 
able circumstances for the success of Brasdor's operation ; because, if it 



430 ANEURISM. 

be not absolutely indispensable, there can be no doubt that it is highly 
desirable that no vessel should originate, either from the sac or between 
the sac and the ligature. And from this it follows that, as the number 
of aneurisms in which that condition can be obtained is comparatively 
few, the utility of the operation is proportionately limited, and moreover 
the danger of the operation is increased by making it necessary to 
include the artery in the proximity of the aneurism. 

Mr. Wardrop suggested his mode of operation for aneurism, so situ- 
ated that neither Hunter's method nor Brasdor's can be adopted ; as, 
for example, for the case of the arteria innominata ; and he was led to 
do so by considering, that if the circulation in the sac be diminished in 
force, though it be not completely stopped, this will be sufficient to 
promote the formation of fibrinous concretion. Mr. Wardrop was the 
first person to perform this operation in a case in which he tied the sub- 
clavian vessel ; it has since been performed by Mr. Evans, Dr. Valen- 
tine, Mr. Mott, Dr. Morrison of Buenos Ayres, M. Langier, Mr. Fearn, 
and others ; but the statistical results are extremely unfavourable, and 
there is every reason to fear that in cases treated according to this 
method, the issue will almost invariably be found unsatisfactory. Cer- 
tainly this mode of treatment has not gained the favourable opinion of 
the profession. 

TREATMENT OF ANEURISM BY PRESSURE. 

Pressure has long been employed in the treatment of aneurism, and 
is much recommended by many of the earlier writers ; but its good 
effects seem to have been much overrated, for although the records of 
surgery furnish examples of the cure of aneurisms under the employment 
of pressure, yet there is reason to believe that until of late years, when 
this mode of treatment has been revived and employed on more scientific 
principles than formerly, the cures were in great measure owing to the 
quietude, abstinence, and depletion which were practised at the same 
time, and which, even though unaccompanied by pressure, would tend 
to promote a spontaneous cure. The pressure was applied sometimes 
to the whole limb, sometimes to the aneurism alone, and sometimes to 
the denuded artery ; but the two methods most frequently adopted were, 
to apply it to the aneurism and the artery leading to it, or to the artery 
alone on the cardiac side of the tumour. The former of these two 
methods was adopted by Guattani, who was one of the greatest advo- 
cates for compression in the treatment of aneurism. He used firm com- 
presses over the tumour and the artery leading to it, and applied a 
roller from the under part of the swelling to the upper part of the limb. 
He applied the roller anew, and somewhat more tightly every eighteen 
or twenty days. With this local treatment he combined general blood- 
letting, rest, and spare diet. With regard to the result of this proce- 
dure, Guattani relates that of fourteen cases, four were cured ; in one, 
the treatment was discontinued on account of the pain ; in one, after 
the use of pressure for three years, an operation was deemed advisable ; 
in one, the tumour was diminished, but the result is not stated ; and in 
seven, no benefit was obtained. 

Guattani does not seem to have had an idea, that by this treatment 



ANEURISM. 431 

he obliterated the artery and established a new circulation ; but Scarpa 
conceived that when pressure effected a cure, it was by bringing into 
contact the opposite parietes of the vessel, and producing obliteration 
of the cavity of the artery by adhesive inflammation, a process to which 
the diseased condition of the artery is sadly hostile. In some instances 
Guattani employed pressure for the purpose of exciting suppuration in 
the swelling. 

Pressure on the artery alone at some distance from the aneurism was 
the mode of treatment often adopted ; the limb was left free, and the 
pressure which was employed with the intention of exciting inflam- 
mation in the vessel, and rendering it impervious by plastic deposition, 
was confined to the artery and to the opposite part of the limb. 

This method was successfully employed by several of the French sur- 
geons, particularly by Dubois and Dupuytren. Dubois cured several 
external aneurisms by pressure. In one case of popliteal aneurism, the 
pressure was applied on the front of the thigh on the 25th of February, 
and the patient was presented to the faculty of medicine in Paris on the 
29th of the next month, completely cured. Other French surgeons 
tried this method of treatment ; and in this country Sir William Blizard, 
Sir Astley Cooper, Mr. White, and others ; but the continued pressure 
necessary to induce obliteration caused such insupportable pain, that it 
was often found impossible to persevere with the treatment ; and this 
circumstance, together with the local inflammation, sloughing, and con- 
stitutional disturbance, which often resulted, led to the abandonment of 
it in this country as a means of inducing obliteration of the vessel. 

The treatment of aneurism by pressure has lately been revived, but 
on new and improved principles ; and the new mode of employing it has 
been attended with so great success, that it may now be said to be 
completely established. The ultimate object aimed at being the conso- 
lidation of the contents of the aneurismal sac, its attainment is sought 
by weakening the force of the circulation through the aneurism ; and 
for this purpose pressure is applied to the artery leading to the aneurism 
at a considerable distance from the tumour, and employed to an extent 
only to weaken the force of the circulation, and not to produce oblitera- 
tion of the artery. As this does not require severe pressure, the objec- 
tions made to the former mode of treatment, that it was impracticable 
on account of the pain, and that the pressure often gave rise to severe 
and dangerous local results, cannot be urged against the method which 
is now employed. 

Dr. Bellingbam, one of the surgeons of St. Vincent's Hospital, Dublin, 
has the merit of having suggested this new mode of using pressure, and 
of having proved its success, and brought the subject before the profes- 
sion. He has treated a considerable number of cases with perfect 
success, and his method has been tried with equally gratifying results by 
other surgeons in Dublin, and elsewhere. Dr. Bellingham is said to 
have stated in regard to the favourable impression entertained of this 
mode of treatment, " So highly satisfactory has been the result of com- 
pression in Dublin, that no surgeon of that city would in the present 
day perform the operation of applying a ligature to the femoral artery 
for popliteal aneurism." Liston, Cusack, Hutton, Porter, Greatrex, 



432 ANEURISM. 

Newcomb, O'Farrell, and others, have treated aneurisms by this new 
method with perfect success ; and it may now be said, that this mode of 
treatment has received the approval of all leading surgical authorities, 
with the exception of Professor Syme, whose success in treating aneu- 
rism by Hunter's operation has been so remarkable — he having tied the 
femoral artery twenty times with perfect success for the cure of popliteal 
aneurism. 

In Tuffnell's " Treatise on the Treatment of Aneurism by Pressure," 
published in 1851, I have seen the following satisfactory report of the 
results in thirty-nine cases of aneurism which occurred in Dublin during 
the last eight years : — 

" Thirty-nine cases in all. 

" In thirty, cure perfect and complete by pressure. 

" In one, compression was discontinued, the aneurism not subse- 
quently increasing in size. 

"In two, the ligature was resorted to, and the artery tied with 
success. 

" In three, amputation was necessary, each instance being followed 
by recovery. 

" In one, death took place from erysipelas. 

"In two, death took place from coexisting disease of the heart." 

There are many aneurisms beyond the reach of pressure, and there 
are others in arteries to which it is not adapted ; but such facts cannot 
reasonably be urged as objections against this mode of treatment in 
cases to which it is applicable, especially as its employment is not at- 
tended with the slightest risk to the patient, and even though it should 
be unsuccessful, it will retard the progress of the disease, and interpose 
no obstacle to the subsequent operation by ligature. 

When Dr. Bellingham first called attention to this interesting sub- 
ject, he stated it as his opinion, that it would be unnecessary to employ 
such a degree of pressure as would cause inflammation and obliteration 
of the artery at the seat of the pressure ; but that it would be sufficient 
merely to weaken the circulation through the artery and the sac, thereby 
favouring consolidation by the deposition of lamellated coagulum. In 
some cases treated successfully by this mode, opportunities have occurred 
of making post mortem examinations in consequence of the fatal results 
of other diseases ; and it must have been gratifying to Dr. Bellingham 
to find, that in most of these instances, the main artery was pervious 
everywhere except at the aneurism. After the Hunterian method, the 
main trunk is usually impervious at two parts, namely, at the ligature, 
and at the aneurism, and pervious between them ; after treatment by 
pressure, it becomes closed only at the sac. I am aware of one case 
treated by Dr. Bellinghani's method, in which the artery became im- 
pervious from the seat of the pressure to the aneurism, but this condition 
is not believed to be the most frequent. 

Various contrivances have been employed for applying the pressure. 
It should be constantly maintained and applied at different points, so as 
not to cause irritation of the skin ; and it is therefore desirable to have 
more pads than one in front of the artery. One appliance which has 
been used, is an arc of iron, with a pad behind, and two or more in 



ANEURISM. 433 

front, movable by means of screws ; one pad should be made to press 
against the artery, and when it causes discomfort, another should be 
applied against another point, after which the pressure by the former 
should be slackened. 

The Signoroni Tourniquet has been found a useful apparatus for 
fulfilling the required conditions ; namely, for producing a constant, 
but very moderate pressure, and for applying it at different points, 
according as it can be conveniently borne. The pressure may be re- 
newed at the point where it was first applied, when the parts have 
recovered from the effects of the former application. 

FALSE ANEURISM. 

The various forms of false aneurism, which are of traumatic origin, 
and usually result from unskilfulness in the performance of venesec- 
tion at the bend of the arm are, circumscribed false aneurism, dif- 
fused false aneurism, aneurismal varix, and varicose aneurism. Either 
of the first two varieties, however, may occur in any part of the body, 
if an artery be wounded ; and either of the last two in any part where 
an artery and a vein in proximity to each other, are both wounded. 

Circumscribed and Diffused False Aneurism. — These two varieties 
differ from each other principally in extent, and this depends mainly on 
the condition of the surrounding cellular tissue. If, when an artery is 
wounded, the surrounding cellular tissue or fascia, underneath which the 

Piff. 146. 




blood escapes from the vessel, be dense or firm, a circumscribed false 
aneurism may be the result ; whereas, if the surrounding tissue be loose 
and capable of dilatation, the aneurism which forms, will be diffused. 

When an artery is wounded, as a grand object of treatment is to 
prevent the occurrence of aneurism, the energetic employment of pres- 
sure is most important ; and the best means for this purpose are a gra- 
duated compress and a roller ; a very necessary precaution, however, is 
the previous bandaging of the limb, without which energetic pressure 
cannot be safely employed. If an aneurism be formed, the treatment 
must depend on the state of the parts. If, in consequence of partial 
consolidation of the contents of the sac, the aneurism be but partly 
compressible, either the Hunterian treatment may be adopted, or pres- 
sure according to the improved principles on which it is now applied to 
the treatment of true aneurism ; but if the contents of the sac be en- 
tirely fluid, the proper treatment for effecting a complete cure consists 
in tying the artery both above and below the wounded part. 

Aneurismal Varix. — When, in consequence of a wound, a direct 

Fig. 146. From Liston. 

28 



434 



ANEURISM. 



communication is made between an arterial and a venous trunk, a disease 
may be formed which was first described by Dr. Wm. Hunter, in the year 



1756, and for which, 



at a subsequent period, Dr. 
Fig. 147. 



Cleghorn, of Dublin, 




Fig. 148. 



suggested the name of aneurismal varix. This disease may occur in 
any part of the body where an artery and a vein, in proximity to each 
other, are both wounded ; but it most frequently presents itself at the 
bend of the arm, and results from the transfixing of the median basilic 
vein, and the wounding of the artery in the operation of venesection. 
Thus three wounds are made before the disease takes place ; one on 
each side of the vein, and one in the artery. The wound in the der- 
moid, or superficial side of the vein may heal, but that on the opposite 

side of the vein, and that in the artery 
may remain open, and through these open- 
ings a communication may be established 
between the two vessels. The effects of 
this communication and direct ingress of 
the arterial blood into the venous trunk 
are, that the implicated vein suffers cylin- 
drical widening, and becomes infected 
with sac-like dilatations ; the artery, on 
the distal side of the disease, becomes 
generally smaller, and its coats thinner, 
in consequence, no doubt, of the diminished 
quantity of blood received into it; and on 
the cardiac side of the wound, the artery 
is usually widened, sometimes to a great 
extent, if the disease be of considerable 
standing. This last-mentioned condition, 
namely, the widened state of the artery 
on the cardiac side of the wound, is one 
which has attracted the attention of 
various authorities ; and before a surgeon 
ventures to recommend an operation, he 
must be well satisfied that it does not 
exist, or only in a very slight degree; 
because in the event of the artery being 
very much widened, its inner surfaces can- 
not be placed closely and uniformly in 

Fig. 147. From Liston. 

Fig. 148. Aneurismal varix, following wound of femoral artery and vein, the former 
being enlarged to the size of a portion of small intestine. From a preparation in my 
museum. 




ANEURISM. 435 

apposition ; but the walls of the vessel will be puckered up by the liga- 
ture, and when the ligature is removed, hemorrhage will, in all proba- 
bility, result. If the artery be considerably widened, the pulsation will 
be felt over a broader surface than usual. The accompanying delineation 
is taken from a beautiful example of this condition in a preparation in 
my own collection. The superficial femoral vein and artery were 
wounded, aneurismal varix wasfyie resut, and the vessels were enlarged 
as here represented. 

The symptoms of aneurismal varix are, feeble pulsation of the artery 
on the distal side, and a swelled and tortuous condition of the vein, in 
which a peculiar thrill and bruit are very perceptible. The bruit has been 
compared by some to the purring of a cat, by some to the prolonged 
articulation of the letter R, by some to the noise of the fly-wheel of 
a music-box, and by others to the buzzing of a fly confined in a paper 
bag. The limb beyond the seat of the disease is usually oedematous and 
cold, and the skin often presents a cyanotic hue in consequence of the 
pressure causing congestion, and obstructing the free return of the blood. 

With regard to treatment, as this affection is in most cases merely a 
source of inconvenience, and becomes stationary, palliative treatment, 
consisting of pressure applied over the whole limb, and more powerfully 
over the disease, in all that in such circumstances is deemed advisable; 
but if the symptoms be so urgent as to demand an attempt to accom- 
plish a radical cure, the proper mode of procedure is, by cautious dissec- 
tion, to expose the artery, and to tie it above and below the opening : 
this course, however, cannot prudently be adopted, if the artery be 
widened as above described. From what has been stated it will be 
evident that it is at an early period that an operation is most likely to 
be useful. 

Varicose Aneurism. — The difference between this affection and aneu- 
rismal varix is, that in this the communication between the wounded 
artery and the vein is not direct, but through the intervention of an 
aneurismal sac. The blood having escaped through the wound in the 

Fig. 140 




artery passes into the surrounding cellular tissue, which it distends into 
a sac, and from this sac it is discharged into the vein. The swelling 
in this instance is formed partly by a circumscribed tumour, and partly 
by the dilated vein ; the former usually continues to increase, as the 
blood is thrown out more rapidly from the artery than it is transmitted 
into the vein. The treatment in such cases consists in deligation of the 
artery both above and below the wounded part. The first case of this 

Fig. 149. From Liston. 



436 DISEASES OF VEINS. 

disease which we find in the records of surgery in this island, is one 
which occurred in the experience of Mr. Park, in the Liverpool Hospital. 
On opening the dilated vein, an orifice was found in its posterior part, 
communicating with a sac, which sac on being examined presented an 
orifice leading into the artery. Since this case was recorded, many 
examples have been met with, and they have generally been at the bend 
of the arm, resulting from unskilfulness* or carelessness in the perfor- 
mance of venesection. 

DISEASES OF VEINS. 
PHLEBITIS. 

This term was first applied by M. Breschet, to denote inflammation 
in the venous tissue, an affection of which veins are very susceptible. 
Plebitis may be either traumatic or spontaneous, and may exhibit the 
characters of fibrinous, of limited suppurative, or of diffuse suppurative 
phlebitis. 

FIBRINOUS PHLEBITIS. 

Symptoms. — Fibrinous phlebitis — the adhesive phlebitis of Cruveilhier 
— is the mildest form of this affection, and is characterized by pain, by 
swelling of the limb below the affected part, by oedema of the surrounding 
cellular tissue, sometimes, although not invariably, by more or less 
sympathetic fever of the inflammatory type, and, if the affected vein be 
superficially situated, by linear hardness and redness in the course of 
the inflamed vessel. The pain is increased by the dependent posture, 
by stretching the vessel, and by pressing on the affected part, or on 
the trunk of the vein leading from it. If the inflammation be slight, 
there may be little or no swelling or oedema of the limb, or any symp- 
tomatic fever. When the affected vein is superficial, the hardness in its 
course is very distinct ; and so is the linear redness, unless the disease 
be combined with erysipelas, in which case the redness may not be dis- 
cernible. 

State of the Parts. — The local changes resulting from this variety of 
the disease consist, in the formation of certain unusual conditions of the 
contents of the vein, and an alteration of the state of its coats and of 
the surrounding cellular tissue. There is consolidation of the contents 
of the vein, whereby its calibre is obstructed ; the coagulum is formed 
partly by an inflammatory product which exudes from the coats of the 
vein, and partly by coagulation of the blood. Gendrin found, that 
after insulating a portion of a vein by securing it between two ligatures, 
and after emptying it of its blood, and exciting inflammation by an 
irritant injection, a plastic substance filling up the whole calibre of the 
vessel was formed ; hence it seems warrantable to conclude, that in this 
disease coagulum is partly formed by an exudation from the coats of 
the vein. In some instances, the plug is evidently formed of concen- 
tric layers, and in many, the centre of the coagulum consists of dark 
coagulated blood. At first the coagulum is but loosely attached to the 
interior of the vessel, but subsequently it becomes more strongly adhe- 
rent. The coats become red and thick, by plastic effusion into them. 



DISEASES OF VEINS. 437 

The surrounding cellular tissue becomes the subject of serous infiltration, 
and that in immediate connexion with the vein is often affected with 
plastic exudation, by which means the vein and the surrounding textures 
become firmly adherent to each other ; and in consequence of this and 
of the thickened state of the coats, it has been found in some examples, 
where there has been an opportunity of withdrawing the plug, that the 
vein had not collapsed, but that its calibre remained open, like that of 
an artery. Lymph may thus be thrown out around the vein, and so 
lead to its firm agglutination to surrounding parts ; or into the coats, 
where it will occasion the thickening of the walls of the vein ; or into 
its canal, producing, if it be to a small extent, a coating along the 
interior of the vein, or if in greater quantity, leading to its entire ob- 
struction. The vein may be ultimately converted into an impervious 
cord, or absorption may take place, and its natural condition be re- 
stored. While the circulation is interrupted though the inflamed vein, 
it is kept up by the collateral branches which are in a state of unnatural 
dilatation. 

Treatment. — Low diet, the use of aperient and diaphoretic medicines 
— the free, and, if necessary, the repeated application of leeches, the 
preservation of the part at perfect rest, and in an attitude favourable 
for promoting the return of venous blood, and for relaxing the inflamed 
vein, the employment of warm cataplasms, or of evaporating lotions, or 
of the local vapour bath, whichever may be most agreeable to the feel- 
ings of the patient, constitute the chief parts of the treatment. 

LIMITED SUPPURATIVE PHLEBITIS. 

The constitutional symptoms are of the same character as in the for- 
mer affection, being those of sympathetic fever of the inflammatory 
type ; they are, however, more severe. 

The local symptoms at first differ from those of fibrinous phlebitis 
only in being more intense ; but afterwards, in one or two situations, a 
circumscribed swelling is formed, in which fluctuation and the other 
characters of a small abscess may be detected. Along with the puru- 
lent matter there also exists a coagulum both above and below, by which 
a barrier is presented to the admission of the pus into the general cir- 
culation, and the character of limitation, so essential for the safety of 
the patient, is thus maintained. The purulent matter is, in some in- 
stances, though very rarely, found loose in the vein ; it is usually en- 
veloped in a thin fibrinous layer, and sometimes is actually enclosed in 
the centre of the clot. To determine the mode in which pus is formed 
within inflamed veins, is a matter of great difficulty, and different views 
are entertained on the subject. The opinions of some authorities re- 
specting it are so distinctly expressed in an admirable article on Phle- 
bitis, in Dr. Hassie's Anatomical Description of the Diseases of the 
Organs of Circulation and Respiration, that I cannot forbear transcrib- 
ing the following passages. " The principal question is, whether the 
pus formed in the veins be the result of secretion from the inflamed 
surfaces, or of direct metamorphosis of the blood itself. Gendrin be- 
lieved that he had observed, by the help of the microscope, a direct 
change of the blood-globules into pus-globules, and he endeavoured to 



438 DISEASES OF VEINS. 

prove this by the following experiment ; having, by means of a double 
ligature, isolated a portion of an artery or of a vein, he caused it to 
inflame by injecting an irritant fluid. He then readmitted the current 
of blood, and afterwards confined it by definitely drawing the ligatures 
together again. Hereupon suppuration commenced in the vessel, and 
the blood becoming first coagulated and then deprived of its colour, 
was by degrees altogether converted into pus. This is the experiment 
so frequently cited, and by many held to afford incontestable evidence. 
More recently, M. Donne' has employed the microscope for the purpose 
of demonstrating the conversion of the blood into pus. Having mingled 
the two substances in the proportion of eight to one, he traced all the 
gradual changes wrought in the blood-corpuscles, until after the lapse 
of twenty-four hours none but pus-globules were discernible. On the 
other hand, Gluge (as formerly Vogel in opposition to Gendrin), has 
shown that in water and in every other kind of liquid capable of dis- 
solving their capsules, the blood-corpuscles undergo precisely the same 
modifications of form as those described by Donne. Hence it may be 
reasonably inferred that the blood-corpuscles become destroyed, and 
that ultimately pus-globules alone are to be met with in the fluid, 
serving for the experiment, not that the individual blood-corpuscles are 
transformed into pus-globules. Gluge could not detect any alteration 
in the blood, in consequence of inflammation, beyond the formation of 
what, both by himself and by Valentin, were termed c composite inflam- 
mation-and-exudation-globules.' It would make a material difference 
could it be shown that the liquid, resulting from the solution of the 
blood-corpuscles was, at least partially, capable of conversion into 
organic elementary cells, which, in consequence of the existing inflam- 
mation, assumed the form of pus-globules. This view is, however, 
merely hypothetical, for I have not as yet been able to subject it to the 
test of experiment. Some light may perhaps be thrown upon the point 
at issue, by the further prosecution of E. H. Weber's interesting in- 
quiries concerning the minute globules that slowly revolve along the 
parietes of the vessels, and which, according to that excellent observer, 
are blood-corpuscles modified through the progress of nutrition. The 
assumption that the pus is secreted by the coats of the veins is founded 
upon analogy. Vogel demonstrated the transition of epithelium-cells 
into pus-globules, and the fact has since been amply confirmed by 
Henle, who, availing himself of the discovery of Schwann, "that all 
organic bodies are developed out of nucleated cells,' showed, partly by 
direct observation, partly by analogical reasoning, that out of these 
' primary cells' forms may spring, either normal or pathological, as the 
case may be. Thus pus-globules would originate as the product of in- 
flammation. In accordance with these views, the puriform masses 
generated within the veins, would be developed as follows. First of 
all, the epithelium lining, discovered by Henle, separates from the in- 
ternal membrane of the vein, so as to give to the inner surface of the 
vessel the dull appearance already described, and to render it more 
susceptible of a morbid tinge from imbibition. The next change affects 
the passing blood-corpuscles, which assume a spheroid, or else a gibbous 
appearance, advance with a slow revolving motion or cling to one 



DISEASES OF VEINS. 439 

another, parting with their serum (plasma according to Schultz), and 
with their pigment. The internal membrane of the vessel generates 
new imperfect epithelium cells, which mingle with the altered blood, 
and finally actual pus-globules, which, when congregated in sufficient 
number, completely arrest the current of the blood, and affect the blood- 
corpuscles in the manner already pointed out. The simultaneous effu- 
sion of both fibrin and albumen now serves to complete the formation 
of a plug, which differs in external character, according to its more or 
less rapid development, and to the varying proportions of its constituent 
parts. The plug thus originating, afterwards undergoes farther changes. 
It ought not, however, to be concealed that this description rests, for 
the most part, upon analogy only ; the test of microscopic observation 
having, as yet, demonstrated the above process only in the smallest 
vessels, and by no means in the larger ones." 

The treatment consists in the use of general and local antiphlogistic 
remedies to an extent proportioned to the severity of the symptoms and 
the particular circumstances of the case. The whole body should be 
kept at perfect rest, the affected part being preserved in an attitude 
favourable for relaxing the inflamed vessel, and promoting the return 
of venous blood ; and warm applications should be diligently employed. 
When abscess forms, early and free opening should be made, followed 
by the usual treatment for abscess. 

DIFFUSE SUPPURATIVE PHLEBITIS. 

Symptoms. — This very dangerous form of the disease sometimes 
supervenes on the last-mentioned variety, the barrier to the admission 
of the pus into the circulation giving way in consequence of an increase 
of the circulation, or of some other cause. In such instances a change 
is perceptible, both in the local and constitutional symptoms. The 
local circumscribed swelling subsides, and the constitutional symptoms 
change very speedily from the inflammatory to the worst form of the 
typhoid type, the change being often preceded by shiverings. In many 
instances the characters of the diffuse form are presented from the very 
commencement of the attack. The local signs in such cases are, pain 
of a peculiar, oppressive, sickening kind, increased by pressure on the 
affected vessel, or on its trunk on the cardiac side, by the dependent 
posture, and by extending the inflamed part ; redness, if the affected 
vessel be superficially situated ; diffuse swelling ; and oedema. There is 
great tenderness to the touch along the course of the inflamed vein ; 
but from the absence, both of the plastic effusion and of the coagulum 
of blood, so essential in suppurative phlebitis for the safety of the pa- 
tient, there is neither the linear induration, nor the symptom of a 
knotted cord along the track of the vein. Should death not take 
place very speedily, gangrene may ensue. The accompanying fever, 
especially in a more advanced stage, is of a low or typhoid kind, cha- 
racterized by great prostration of strength, anxiety, irritability, and 
restlessness, a sense of weight at the prsecordia, a very rapid and feeble 
pulse, paroxysms of oppressed and hurried breathing, black sordes on 
the tongue and teeth, frequent nausea and vomiting, especially of 
bilious matter, the countenance sunk and expressive of anxiety and 



440 DISEASES OF VEINS. 

great suffering, a yellowish or sallow appearance of the body, and 
before death muttering delirium. Such are the symptoms of this most 
dangerous disease ; and they are believed to depend on the contamina- 
tion of the blood by direct purulent admixture, pus or a puriform fluid 
being formed very early, and meeting with no obstacle to its mingling 
with the blood. 

Dr. Arnott, in an interesting article in the fifteenth volume of the 
" Medico-Chirurgical Transactions," gives the particulars of many fatal 
cases, and his own conclusions from them. His observations led him to 
conclude, that there are great differences as to the extent of the vein 
occupied by inflammation in fatal cases ; that in the great majority of 
cases pus is found within the veins ; that there is a striking resemblance 
between this form of phlebitis and diseases arising from the inoculation 
of morbid poison, and that death does not take place from extension of 
the inflammation to the heart, such extension being a very rare occur- 
rence indeed, as the inflammation usually terminates abruptly where a 
cross current flows into the main trunk through a collateral branch ; 
but that the entrance of pus, or of some other product of inflammation, 
is the source of the fatal symptoms. 

Morbid Changes. — As has been already stated, purulent matter is 
usually found within the vein ; which matter not being circumscribed, 
as in the limited form, finds no barrier to its admission into the circula- 
tion ; " the fibrinous dykes" (to use the expression of an excellent 
writer on surgery) being wanting. There are three situations which 
the pus may occupy, namely — the interior of the vein, the cellular mem- 
brane connecting the coats with each other, and the surrounding cellular 
tissue, which is often infiltrated to a great extent. 

There are many important sequelae which present themselves in 
various parts of the body remote from the seat of the phlebitis — but 
they are all thought to be divisible into two grand classes, the first com- 
prehending such as are referable to the coagulation of the blood in the 
large venous or arterial trunks, in the central parts of the vascular 
system, or. even in the heart itself; and the second, certain lesions 
which have their seat in the capillary system. 

The coagulation of blood consequent on phlebitis has been met with 
most frequently in the pulmonary artery. An author, on this subject 
says : — " It would appear that in such cases, the product of inflamma- 
tion, be it pus or finely-divided fibrin, follows the course of the blood 
towards the heart, but advancing more slowly than the uncontaminated 
blood, accumulates, invests itself again and again with fresh layers of 
coagulum, and ends by entirely closing up the calibre of individual 
vascular trunks." 

The sequelae which have their seat in the capillary system, consist of 
lesions which have been designated by the appellations " lobular inflam- 
mations," and " lobular abscesses." These secondary infiltrations are 
most commonly found in the lungs and liver, especially in the former ; 
they usually present themselves in the form of deposits disseminated 
through the parenchyma of those viscera, and differ from abscesses in 
being neither encysted, nor concentrated into one place. In the chest 
the lungs are the organs most frequently affected, but sero-purulent 



DISEASES OF VEINS. 441 

effusions are also met with in the pleurae, the pericardium, and even on 
the surface of the heart itself. In the abdomen, the liver is most fre- 
quently the seat of such deposits ; in the spleen, and in the kidneys, they 
are very rarely found. The cellular tissue, both subcutaneous and inter- 
muscular, is very liable to become the seat of purulent deposits, the 
matter being deposited sometimes as in abscess, and sometimes by infiltra- 
tion. Such deposits are most common in the cellular tissue around joints. 
Purulent effusions into the synovial membranes of joints, and even 
destruction of their cartilages, are well known to practical observers as 
frequent lesions. Phlebitis is also sometimes attended by inflamma- 
tion of the membranes of the brain and effusions under them, and even 
by effusions into the ventricles ; but deposits into the substance of 
the brain, as sequelae of phlebitis, are extremely rare results. In va- 
rious instances the eye has been rapidly destroyed ; the cornea becoming 
swollen, and eventually bursting, or becoming totally disorganized. 
Veins, also, quite remote from those originally diseased, seem liable to 
secondary suppuration. In regard to these lesions, Professor Hassie 
thus expresses himself: — "Another question still presents itself, namely 
— whether the pus formed within veins at the part originally inflamed 
be substantively transmitted through the medium of the circulating 
current to the lungs, the liver, &c, to accumulate at certain points 
within the latter ; or whether it be actually generated in the parenchyma 
of those organs. The former opinion was at one time zealously main- 
tained, and numerous observations were adduced in evidence of such 
metastasis. More recently, however, the latter view has prevailed ; 
and, although in these processes there is still much that remains to be 
cleared up, yet an unbiassed comparison of the facts has furnished an 
explanation adequate to the majority of cases. With regard to lobular 
abscesses, there cannot, at the present day, be any further question of 
the pus being conveyed to them, exclusively and in quantity, by the 
circulation. The best authorities have repeatedly asserted that these 
collections are not at once purulent at the outset, but knots form, of 
from the bigness of a pea to that of a walnut, become infiltrated with 
firm coagulated blood, and eventually suppurate. I have had opportu- 
nities of convincing myself of the correctness of this fact with reference 
to the lungs, the liver, and the spleen. It may be, therefore, concluded 
that owing to some obstacle, the blood stagnates at certain points, pro- 
ducing suppurative inflammation of the surrounding tissues. 

" The experiments of Leuret, Trousseau, and others, and of Cruveilhier, 
afford an insight into the cause of such stagnation ; for when putrid and 
other substances are injected into veins, organic changes perfectly ana- 
logous to those above described, are developed with the accompaniment 
of low typhoid fever. The experiments of Giinther are the most striking 
of all in their results. Having injected pus into the veins of horses, he 
very shortly afterwards found fully-formed lobular abscesses in the lungs. 
From these data we may, with some degree of certainty, infer that pus 
is conveyed in substance by the veins to the heart, and forwarded from 
thence ; but that those pus-globules, which have reached the capillaries 
of the lungs in their entire state, are unable, from their size, to per- 
meate the latter. These globules now become a central point of stag- 



442 DISEASES OF VEINS. 

nation (and, finally, of extravasation) in the adjunct branches of the 
pulmonary artery, and thus determine, eventually, local inflammation 
and suppuration. 

"In this manner phlebitic abscesses in the lungs are satisfactorily ac- 
counted for, as are also those which occur in the liver, in consequence of 
inflammation within the tract of the portal system. The origin, how- 
ever, of purulent collections in other organs still remains obscure. Here, 
indeed, the above explanation is inapplicable, founded, as it is, upon the 
inability of the pus-globules to permeate the minute capillary vessels of 
the lungs. Gunther found that these deposits were formed subsequently 
to those in the lungs, and believed that they originated from pus being 
taken up from the diseased parts of the lungs by the pulmonary 
veins, and thus carried into the greater circulation. Were this ex- 
planation correct, phlebitic abscesses must, necessarily, exist in the 
lungs, wherever such deposits are found in the capillary system of 
the greater circulation. To ascertain this, I have compared a large 
number of cases, observed partly by Balling, Dance, Arnott, and 
others ; partly by myself. Amongst them, however, there are only 
two (one related by Sasse, of purulent deposits in the liver, and one by 
Dance, of purulent exudation within the wrist-joint), in which the non- 
existence of pulmonary abscesses is established by careful examination 
after death. Four of Arnott's cases — the first, third, seventh, and 
ninth — would certainly appear to belong to the same class ; they are, 
however, not related sufficiently in detail to admit of any decided infe- 
rence being drawn. It is singular, indeed, that the seat of the purulent 
secretion, in those four instances, was within serous sacs — in three of 
them, within those of different articulations, and in one, within that of 
the pleura. It may, upon the whole, therefore, be assumed that in some 
cases the substances commingling with the blood, pass through the 
capillary system of the lungs, without inducing any changes in the pul- 
monary parenchyma. Vogel, without, indeed, assigning any reason, 
considers it not impossible for single pus-globules to pass through the 
capillaries of the lungs ; it is perfectly intelligible, at all events, that 
the nuclei of ruptured pus-globules may pursue their course, without 
hindrance, into the greater circulation. This applies equally to fibrin 
altered by the inflammatory process, finely-divided particles of which 
will, if hurried along by the circulating current, be, in many cases, pro- 
ductive of the same effects as pus." 

Causes. — Phlebitis seldom originates spontaneously, and can, in most 
instances, be traced to some injury done to the vessel itself, or to the 
communication of inflammatory action from some contiguous textures. 

Injuries affecting bones, as has been particularly pointed out by Cru- 
veilhier and others, often give rise to venous inflammation. A blow, 
pressure, extension of inflammation from ulcers, cold, suppuration in the 
shaft of a bone after amputation, are all causes of phlebitis. It is well 
known that in the Hotel Dieu of Paris, lobular pneumonia, induced by 
phlebitis, was at one time a frequent cause of death among patients 
on whom operations had been performed. Other ordinary causes of in- 
flammation of veins, are wounds of veins by accident, or in venesection, 
or other operations in which veins have been wounded or tied ; and hence 



VARICOSE VEINS. 443 

arises the necessity of avoiding, as much as possible, any interference with 
veins, and especially of not including them in ligatures, except under the 
most urgent circumstances. Many fatal examples have resulted from ve- 
nesection, owing mostly to the use of a dirty lancet in bleeding, or to too 
free an exercise of the limb before the wound has properly healed ; or 
to an irritable or unhealthy state of constitution, which not only pre- 
disposes most strongly to an attack on the application of an exciting 
cause, but modifies, in a great degree, the character of the inflammation. 
Symptoms, — While the symptoms are of the sthenic type, the local 
and constitutional treatment formerly recommended should be adopted; 
but when typhoid symptoms appear, or when the constitutional affection 
is, from the commencement, of the asthenic character, while the same 
local treatment, more or less modified according to circumstances, is 
proper, the object aimed at by constitutional treatment should be, to 
support the strength and to allay as much as possible the irritative fever; 
for which purpose the means generally employed are, diffusible stimu- 
lants, wine, light nourishment, and the use of calomel and opium, or 
calomel in combination with some of the preparations of morphia. No 
treatment, however, as yet suggested, is found to have much effect in 
arresting the progress of the disease, and, consequently, the prognosis 
in this form of phlebitis is extremely unfavourable. 

VARICOSE VEINS. 
CAUSES, ANATOMICAL CHARACTERS, AND TREATMENT. 

Varix, which has been defined to mean, "a vein preternaturally 
dilated without the dilatation being instituted to answer any good pur- 
pose in the animal economy," may originate in any permanent obstruc- 
tion to the venous return, as for instance, in pressure on the venous 
trunks above, induced by distended rectum, by diseased liver, by the 
gravid uterus, by aneurismal or other tumours; or it may arise from 
some obstacle to the passage of the blood through the heart or lungs, or 
from relaxation or weakness of the coats themselves. According to 
some authorities it arises more frequently from weakness of the veins 
than from any other cause. In some examples, obstruction from inflam- 
mation in the vein itself has been supposed to give rise to the disease ; 
and, in some, violent and sudden muscular exertion has occasioned it. 

Varices occur principally in three situations, namely, in the lower 
extremities, in the spermatic cord, when the disease is termed varicocele ; 
and about the lower part of the rectum, constituting the disease called 
hemorrhoids, or piles. Varicose veins occur occasionally in other parts 
of the body, various examples of which are recorded, and in most of 
them the disease could be clearly traced to some obstruction to the 
return of the blood by the venous trunks leading from the affected part. 
It is to varices in the lower extremity that- the following observations 
are intended to apply. It is an extremely rare thing for the deep- 
seated veins to be the subjects of this disease, in consequence of their 
coats being supported by surrounding textures. The vessels which 
afford examples are the vena saphena interna, and the vena saphena 
externa ; but principally the former, the branches of which about the 



444 VARICOSE VEINS. 

ankle and inner part of the leg are often affected. These veins are so 
situated that their coats receive little support from surrounding struc- 
tures to aid them in resisting the dilatation caused by accumulation of 
blood within them. 

The calibre of a vein affected with this disease is enlarged. The 
vessel is not only dilated, the dilatation either being nearly equable, or 
presenting sacculated or knotty protuberances on various parts, but it is 
also elongated, and thereby becomes tortuous. In many instances the 
vein exhibits a very irregular aspect, being equably wide at some parts, 
comparatively narrow at others, and at others dilated into irregularly 
shaped cavities. The enlargement may be accompanied either by 
increased or diminished thickness of the coats, or by both states at dif- 
ferent points. The state of the coats, however, is not the same in the 
different forms of varix, nor in the same form at different periods. 
Professor Hassie of Zurich, makes the following observations on this 
subject. " In persons affected with a morbid preponderance of the 
venous system, we first of all observe an undue prominence of the veins 
of the skin. These appear in dense nets of branches, remarkable for 
their diffuse distribution, and are generally turgid with blood, or liable 
to become so from the slightest mechanical or dynamical causes — like 
what, under ordinary circumstances, would be the effect of violent and 
prolonged muscular exertion. In this condition of the veins their coats 
have not undergone any absolute change, being everywhere propor- 
tionate to the width of the calibre ; the vessels are not more than usually 
tortuous, and cannot as yet be called morbidly altered ; after a while, 
however, the veins become permanently dilated, an occurrence more 
frequent in elderly than in young persons. This is brought about by a 
reinforcement of the fibrous texture of their external coat, in the shape 
of an accession of conspicuous transverse fibres. Meanwhile the internal 
membrane remains unchanged in structure, merely displaying numerous 
lines of superficial furrows running lengthwise, and the vessel still 
maintains its natural course, not assuming a more sinuous, but rather, 
if anything, a straighter direction than before. It does not collapse 
when cut through, but remains patent, and is distinguishable from the 
arteries by its colour, which is of the same pale red as the fibro-felt-like 
texture constituting the normal external membrane of a vein. The 
valves remain unaltered. In this condition the saphena is frequently 
found in old persons ; so likewise are certain branches of the vesical 
plexus, whilst other branches manifest still farther changes. In the 
greater number of instances, however, the external membrane of the 
vein is not thickened, but, along with the other membrane, undergoes 
considerable attenuation, in proportion as the vein becomes more and 
more dilated. Conformably with their irregular disposition, the inter- 
mediate fibres give way unequally, allowing the internal membrane to 
jut out in sac-like protrusions, and to establish so many irregular, 
constricted, pear-shaped, and often in appearance, pediculated tumours. 
At the commencement of some of the smaller branches the membrane 
thus forms pouch-like dilatations, or forces itself between the longitudinal 
fibres of the external membrane in lengthy protuberances, which exceed 
in circumference that of the vein in its natural state; or, it may, 



VARICOSE VEINS. 445 

perhaps, distend cylindrically and pretty equably for a considerable 
length the intermediate fibres before alluded to. Meanwhile the valves 
become attenuated, and pulled asunder transversely, so as to be rendered 
useless ; in many instances they become partially or wholly obliterated, 
and are torn into shreds, or destroyed as far as their free border, which 
then runs across the diameter of the vessel like a filament or band, 
attached by the two extremities to the internal membrane. The veins 
now appear elongated, and their course very tortuous." 

Professor Andral has described six different forms of enlargement of 
veins which he has met with in dissection, but many pathologists ques- 
tion the propriety of classing some of them with varices. They are the 
following : — 

1. Simple dilatation without any other change. 

2. Equable dilatation with attenuation of the coats at the affected 
part. 

3. General dilatation, and a tortuous condition, w T ith thickening of 
the coats. 

4. Partial dilatation, with thickening of the coats. 

5. Dilatation, with septa within the veins. These septa, as will be 
understood from what is stated above, are not now regarded as of new 
formation. 

6. Dilatation, with septa and perforations in the coats, by which per- 
forations the cavities of the veins and the surrounding cellular tissue 
which is diseased, communicate. The kind of disease of the cellular 
tissue will be considered under the head of the anatomical characters of 
hemorrhoids. 

Varicose veins at first contain blood in a fluid state ; but an alteration 
of the contents, which frequently occurs, is the coagulation of the blood, 
whereby the vessels become obstructed. The formation of coagula is 
considered to be a product of inflammation, varicose veins being liable 
to be attacked by that process, and, as was stated in the description of 
the anatomical characters of some of the forms of phlebitis, coagulation 
of the blood is an early result of inflammation when it attacks the venous 
tissues. 

In many instances varicose veins create little inconvenience ; in 
others they cause much discomfort and annoyance by pain, fulness, and 
weakness of the affected part, aggravated by exercise and the erect pos- 
ture ; but the following results are not unfrequent — phlebitis, hemor- 
rhage, certain conditions of cellular tissue, varicose ulcers, and inflam- 
mation of the skin. 

Inflammation of the vein may be of a low grade, giving rise to coagu- 
lation of its contents ; or it may affect both vein and cellular tissue, and, 
reaching the suppurative grade, give rise to small abscess in the first 
instance, and afterwards to varicose ulcer, although this is not, as will 
hereafter be stated, the mode in which the form of ulcer denominated 
varicose usually originates. Phlebitis, when a consequence of varicose 
veins, usually assumes the form of fibrinous phlebitis, producing destruc- 
tion, or of limited suppurative phlebitis, but very rarely indeed that of 
the diffuse suppurative variety. In some instances, the vein and super- 
ficial parts have become so greatly attenuated as to produce bursting of 



446 VARICOSE VEINS. 

the vessel, followed by serious, and occasionally even by fatal hemor- 
rhage. The valves being rendered incapable of performing their office, 
the pressure of the column of blood may give rise either to inflammation, 
or to increase of dilatation, and eventually to hemorrhage, which, as 
there is no obstacle to the descent of the blood from the trunks of the 
veins, may be excessive. 

Other conditions of frequent occurrence are, oedema of the cellular 
tissue, merely from obstruction of circulation ; or ©edematous effusion, as 
a product of a low grade of inflammation of the cellular tissue, when the 
substance effused is of a less fluid character than when the oedema arises 
from the obstruction to free circulation ; or, if the inflammation be of a 
rather higher grade, the cellular tissue may be consolidated by effusion 
of lymph. Such are the more frequent conditions of the cellular tissue 
surrounding varices in general ; but in that variety which constitutes a 
form of hemorrhoids, a different state of cellular tissue is found, as will 
be stated in another section. 

Varicose ulcers are frequent consequences of varices, and they arise 
either from limited suppurative phlebitis ending in abscess, and the for- 
mation of an ulcer, or from inflammation of the skin, which either cracks 
or has a scab formed over an irritated and inflamed part, where an ulcer 
ultimately forms. 

Treatment. — The treatment of varicose veins is either palliative or 
radical: the former has now almost entirely superseded the latter, and 
in the opinion of the writer ought always to be preferred, except when 
the disease endangers the life of the patient. 

Palliative Treatment. — One of the most important indications, except 
in the case of pregnancy, is to remove, if possible, the exciting cause ; 
and for that purpose remedies adapted to the particular circumstances 
of the case ought to be prescribed. In all cases it is advisable to pre- 
serve the bowels in a regular state — to enjoin the use of light nourish- 
ment, but with abstinence from liquids — to direct the patient not to 
remain long in the erect posture — to remove from time to time from the 
weakened vessels the weight of the superincumbent column of blood — to 
recommend that the recumbent posture be frequently assumed in order 
to favour the return of blood, and that violent or long-continued muscu- 
lar exertion be avoided ; and, except in the case of phlebitis, to support 
the weakened vessels by means of pressure. For this last purpose, a 
common roller, or a starched bandage, or elastic bandages of India-rub- 
ber, are sometimes used ; but the two most convenient appliances, as 
affording a very equal pressure, are an elastic stocking, or an elastic 
bandage of stocking web. The pressure should be sufficient to afford 
support, and to diminish the size of the dilated veins, but not to produce 
any undue constriction of the limb. 

If the varicose veins be affected with phlebitis, pressure will be ex- 
tremely injurious. In such cases the treatment consists, in preserving 
the whole body at perfect rest, — keeping the affected limb in the hori- 
zontal posture, — applying leeches in the neighbourhood of the vein, — 
employing either cold lotions or warm applications, as may be most 
grateful to the feelings of the patient ; together with the strict observ- 
ance of antiphlogistic regimen. 



VARICOSE VEINS. 447 

Radical Treatment. — It would answer no useful purpose to explain 
all the methods which have been adopted for effecting a radical cure. 
Among them the following deserve to be noticed : — 

1. Puncturing the vein, a plan proposed by Hippocrates, evacuating 
its contents, and stopping the hemorrhage by means of pressure. 

2. Excision, originally proposed by Celsus, checking the hemorrhage 
either by tying the trunk at each extremity of the cut portion, or re- 
straining it by pressure. 

3. Tying the vein, a proceeding anciently proposed by Aetius and 
Paulus JEgineta, has been revived and strongly recommended by Sir 
Everard Home, and adopted (with differences in the mode of tying) by 
Ricord, Tavignot, and some others. For the cure of varicose veins of 
the leg, Sir Everard Home tied the saphena interna by dividing the 
skin over it, and passing a needle armed with a ligature under the vein. 
The object of his operation was, to produce obstruction of the principal 
trunk leading from the varix. In some cases it was believed that bene- 
fit was derived ; but several cases having proved fatal, these unfavour- 
able results put a stop to so hazardous and unjustifiable a practice, 
which for the removal of an inconvenience, placed a patient's life in 
the greatest danger. As obstruction of circulation through a venous 
trunk is often the cause of varix, it is difficult to understand on what prin- 
ciple the operation of Sir Everard Home can prove useful, except where 
the venous trunk itself has become so greatly distended that its valves 
are unable to prevent the weight of the column of blood in the venous 
trunk from pressing on its branches. Some surgeons think it useful 
by promoting collateral circulation, so that the blood is returned by 
different channels. Sir Benjamin Brodie, in stating objections to this 
operation, remarks, "But still there is another reason against having 
recourse to this operation. I do not believe, from what I have formerly 
seen, that it permanently benefits the patients. It is true that they 
appeared to go out of the hospital much relieved ; but where I had the 
opportunity of seeing them one or two years afterwards, I always found 
them as bad as ever. Indeed, I am by no means certain that the benefit 
which the patients seemed to derive, in the first instance, was the result 
of the operation ; and I am more inclined to believe that it arose from 
their having been necessarily kept for some time in bed in the horizontal 
posture." 

4. Cutting through the vein. Various modes of this operation have 
been adopted ; but of all with which I am acquainted, the safest ap- 
pears to me to be that proposed and practised by Sir Benjamin Brodie, 
who used a narrow sharp-pointed bistoury with the edge on the convex 
side, and when his object was to cure a cluster of varicose veins, he in- 
troduced the instrument through the skin, carried it flat between the 
skin and the veins, and then directed the edge against the veins, and in 
withdrawing the instrument cut across the veins, leaving but a very 
small wound in the 'skin ; the hemorrhage he arrested by the pressure 
of a compress. He was induced to try this operation from observing 
that, although operations on large veins are apt to lead to dangerous 
results, there is no reason to fear danger from operations on the smaller 
branches. In reference to this mode of subcutaneous division of varicose 



448- VARICOSE VEINS. 

veins, Sir Benjamin Brodie observes, "As applied to varicose veins, 
the operation is as easy and as safe as it is on other occasions ; yet I 
scarcely ever have recourse to it now. With my present experience it 
really appears to me that in ordinary cases it is not worth the patient's 
while to submit to it, as I always observed that, if I cured one cluster, 
two smaller ones appeared, one on each side, and that ultimately I left 
the patient no better than I found him. The operation, however, is 
proper, where there is a varicose cluster much distended, and liable to 
burst and bleed; Here you may actually save the patient's life by 
having recourse to it ; and you may do so without considering whether 
fresh clusters are or are not likely to form afterwards." 

5. Pressure by means of a needle and twisted suture in order to 
effect obliteration of the vein has been practised with considerable suc- 
cess by M. Velpeau. He introduces a needle underneath the vein, and 
applies a twisted suture round its ends, and if considerable inflammation 
supervenes, he withdraws it in a few days, his object being to induce 
sufficient inflammation to reach the fibrinous grade, and thereby to 
cause occlusion ; but if little inflammation result, he allows the needle 
to eat its way through. Few serious consequences appear to have 
resulted from this operation ; and it is therefore regarded less unfavour- 
ably than various other modes for attempting obliteration of varicose 
veins. 

6. Cauterization. — The potassa fusa has been applied to different 
situations, and in different forms, according to the different immediate 
results through which it is hoped to effect the cure. One method is, to 
apply the potassa fusa over the venous trunk, and to employ it so freely 
as to produce a slough of the vein together with that of the surrounding 
parts. The change desired in this method is the permanent obstruc- 
tion of the canal of the vein by the destruction of a part of the trunk 
and fibrinous inflammation in the parts surrounding the slough. Pres- 
sure is applied to the dilated veins ; and when this method proves 
beneficial, it is believed that this result arises from the blood being forced 
to return by collateral circulation, by which means the distended vessels 
become unloaded, and are placed in circumstances more favourable for 
recovering tone or becoming consolidated. Another method is, to apply 
the potassa fusa not over the venous trunks leading from the disease, 
but over the varix itself, and at different points, using it so freely as to 
induce sloughing of the veins together with the surrounding tissues. A 
third method, suggested and practised by Mr. Mayo, consists in applying 
the caustic over the vein, but not so freely as to induce a slough ; the 
object being to bring on fibrinous phlebitis, and thereby to cause per- 
manent obstruction. A fourth mode is, the application of the Vienna 
paste — a compound of five parts of quick lime, and four of caustic 
potash made into a paste with spirits of wine. It is applied to various 
parts along the course of the diseased veins, the surrounding parts being 
protected by some plaster ; the diameter of each part to which it is 
applied should be about one-third of an inch, the number of parts 
varying according to the extent of the disease ; and the length of time 
during which the application should be continued is about half an hour. 

Such are the principal methods which have been employed for the 



VARICOSE VEINS. 449 

radical cure of varices, and such the different opinions entertained as to 
the process, by which each is expected to conduce to the end desired. 
Division, as practised by Sir Benjamin Brodie, cauterization by means 
of the Vienna paste, and obstruction by pressure by means of a needle 
and twisted suture as proposed and practised by M. Velpeau, are the 
methods most favourably regarded ; and of them all, the subcutaneous 
section of the veins as practised by Brodie, I should think the least 
hazardous, and consider warrantable and advisable, when the disease 
gives rise to great discomfort, or threatens dangerous hemorrhage ; but 
in all other circumstances it appears to me to be a matter of very ques- 
tionable propriety, to venture upon a proceeding which endangers the 
life of a patient, merely to relieve him of an inconvenience. 

I consider that in the great majority of cases, the palliative treatment 
is preferable to any of the methods proposed for effecting a radical cure. 



29 



450 



CHAPTER XIII. 

DIFFERENT KINDS OR CLASSES OF ABDOMINAL HERNLE. 

Abdominal hernise, or ruptures, are usually divided, if their condition 
is taken as the basis of arrangement, into three classes ; namely, reduci- 
ble^ irreducible, and strangulated ; or, if they are arranged according to 
situation, into four ; namely, inguinal, femoral, umbilical, and ventral. 
It will help to a clearer understanding of the subject, if we consider 
these two divisions separately, giving under the first, the general doc- 
trines of hernia, and under the second, the different forms of hernia, as 
they present themselves in the living body. 

REDUCIBLE HERNIA. 

Definition. — A hernia is reducible, when it can be easily returned 
into the cavity of the abdomen. 

Symptoms. — In reducible hernia there is a swelling, which presents 
the following characters : — It is unattended with heat, discoloration, 
tenderness, pain, or even uneasiness, except when the tumour first takes 
place, at which period an uneasy sensation of weakness in the parts is 
in some instances complained of. The swelling begins from above, and 
gradually descends ; it is brought on by the erect posture, coughing, 
sneezing, pressing on the abdomen, or by any exertion of the abdominal 
muscles or diaphragm ; and it disappears in the recumbent posture, or 
when gentle pressure is applied. During coughing it becomes larger 
and tense, and communicates a sudden impulse to the hand of the exa- 
miner. These symptoms may be observed in every reducible tumour ; 
but there are others, which, although more variable, characterize a 
hernial tumour, and when present, furnish information regarding its 
contents. If the swelling be elastic, uniform, and compressible, and if 
its return be sudden and attended with a peculiar guggling noise (the 
gargouillement of the French writers), there can be no doubt that the 
hernia is formed of intestine. The smooth surface of the intestine 
makes its return easy and sudden, and the mixture of air with other intes- 
tinal contents gives rise to the peculiar guggling sound. If the swelling 
be more solid and uneven,— if it feel heavy to the patient, — if it be 
doughy to the touch, and receive an impression from the fingers of the 
examiner, and if its return be gradual and unattended with any peculiar 
sound, there can be no doubt of its being an omental hernia. When 
omentum forms the hernia, its surface becomes moulded by the surround- 
ing parts, and in consequence, its return into the abdomen is gradual. 
If a portion of the swelling be elastic, and return suddenly with a gug- 
gling noise ; and if the remaining part be doughy, and its return more 



HERNIA. 451 

gradual and less easily accomplished, the hernia is in all probability 
formed of intestine and omentum. These discriminating symptoms, 
when well marked, as they usually are in hernia of short standing and 
moderate size, furnish very satisfactory information regarding the con- 
tents of the hernia ; but if the hernia be small, it is often difficult and 
even impossible to arrive at a decided conclusion as to its contents ; and 
if it be of long standing, there is frequently the same difficulty, since 
the thickening of the hernial sac, and the adhesion of the parts of the 
hernia to each other, and change of structure, diminish the accuracy of 
any nice discrimination by the touch. When the hernia is formed of 
intestine alone, it is called an Enterocele ; when of omentum alone, an 
Epiplocele; when of both intestine and omentum, an Entero-epiplocele ; 
and when of a redundant portion of bowel in the form of a diverticulum, 
a Hernia Litrica. 

Treatment.— The treatment of reducible hernia consists in returning 
it into the abdomen, and preventing its recurrence by the pressure of a 
truss. A reducible hernia generally goes up of itself, when the patient 
is placed in the horizontal posture and more especially if the thigh on 
the affected side be brought a little upwards and inwards, so as to relax 
the parts about the hernia. When it does not return of itself, it may be 
replaced by certain manual proceedings, technically called the operation 
of the taxis — the manner of performing which varies in some respects 
according to the situation of the hernia, as will be explained hereafter. 
Pressure by means of a truss is employed for the purpose of preventing 
a recurrence of the hernia. While the patient requires to use a truss, 
the treatment is palliative or preventive ; when it has induced such a 
change as to prevent any tendency to a recurrence of the hernia, the 
cure is said to be complete or radical. There is no period of life at 
which a truss may not be used. At one time it was supposed that it 
could not be applied to a child ; but it is now ascertained that if a truss 
be sufficiently weak, it may be worn by the youngest children without 
inconvenience; and as a complete or radical cure is readily produced in 
early life, it is of the greatest importance that the application of a truss 
should not be delayed. The only condition of parts in early life which 
forbids the use of the truss is the testicle not having descended through 
the inguinal canal. The pressure and thickening of parts, under these 
circumstances, might present an obstacle to the descent of the testicle, 
and cause its permanent retention in the abdomen ; but fortunately this 
condition of the testicle is of rare occurrence. If, however, it should 
present itself in a case of reducible hernia, the application of the truss 
ought to be delayed until the testicle has made its way into the scrotum. 

In regard to the use of a truss, the following points are highly 
deserving of consideration : — 

1. The different ways in which the use of a truss produces a complete 
cure of hernia. 

2. The precise situation in which the pressure should be applied by 
means of a truss. 

3. The length of time a truss ought to be employed for the cure of a 
hernia. 

4. The chief sources of inconvenience and irritation from wearing a 
truss. 



452 HERNIA. 



I. THE DIFFERENT WAYS IN WHICH THE USE OF A TRUSS PRODUCES A 
COMPLETE OR RADICAL CURE OF HERNIA. 

First. — If a hernia has been very suddenly produced^ if it be very 
small, and if it be very quickly returned, the hernial sac may either 
return with the hernia, or be gradually drawn back into the cavity of 
the abdomen. The sac being empty, and no force pressing it down- 
wards, its ascent will be promoted by the elasticity of the peritoneum 
lining the walls of the abdomen in the neighbourhood of the protrusion, 
and by the stretching of the peritoneum in various movements of the 
body, as well as by the elasticity of the hernial sac itself. After the 
return of the sac, the pressure of a truss sometimes produces sufficient 
diminution of the opening by contraction, effusion of lymph, and conse- 
quent joining of the surfaces, to prevent any future protrusion of sac or 
hernia. This kind of cure, however, in which the sac returns, and its 
future protrusion is prevented by the diminution of the opening, is only 
to be looked for in small hernise of short standing, and very suddenly 
produced. If i hernia be of considerable size, and more especially if it 
be also of long standing, the distension of the hernial sac, and the pres- 
sure of the surrounding parts excite a degree of inflammation by which 
those parts and the sac become adherent to each other, so that the sac 
cannot be returned into the abdomen, and the kind of complete cure 
already described cannot take place. 

Second. — After the return of a hernia, the sac being empty contracts 
by its own elasticity, in accordance with the general law, that membra- 
nous parts accommodate themselves to the state of their contents. This 
kind of closure of the hernial sac is analogous to the contraction of the 
tubular portion of peritoneum, which exists within the inguinal canal 
for some time after the descent of the testicle. A truss, by approxi- 
mating to each other the sides of the hernial sac, may assist the natural 
elasticity in closing up its neck, and in bringing about a radical cure. 

Third. — Occasionally the wearing of a truss for a long time produces 
thickening of the neck of the sac, or of the cellular tissue surrounding 
it, or of both, and thus interrupts the communication between the cavities 
and the abdomen, and the hernial sac. 

Fourth. — The pressure of a truss often excites adhesive inflammation 
in the sac, by which its opposite sides become joined together by coagu- 
lable lymph, and a recurrence of hernia is prevented. This condition 
of parts is very frequently found in the bodies of persons who have been 
subjects of hernia. 

Fifth. — According to J. Cloquet the opposite sides of the sac some- 
times become adherent without the intervention of lymph, and without 
the very slightest traces of any inflammation. He supposes that the 
membrane ceases to secrete the fluid by which it is naturally bedewed ; 
that it becomes dry, and that the sides become adherent without the 
intervention of any substance. In the ordinary form of adhesion of the 
opposite sides of a hernial sac, effusion of lymph, thickening of the sac, 
and traces of adhesive inflammation are perceptible, whereas in this 
method of complete cure there is immediate union, with thinning of 
the peritoneum, and the entire absence of all traces of inflammatory 
adhesion. 



HERNIA. 453 

Sixth. — Pare*, Arnaud, and others, record cases in which complete 
cures were effected by the firm adhesion of the formerly protruded parts 
to the peritoneum lining the abdomen around the mouth of the hernial 
sac ; and as in these cases trusses had been worn, it was believed that 
the pressure gave rise to inflammation in the neck of the sac, and that 
this inflammation, having extended to the membrane lining the cavity 
of the abdomen, produced the adhesions. 

Seventh. — Absorption of the neck and part of the body of the sac 
sometimes produces radical cure. Surgical observers have described 
this condition of parts, and I lately had an opportunity of demonstrating 
it to the students at the School of Medicine in Marischal College, in the 
body of a person who had worn a truss for many years for the cure of a 
reducible hernia. Almost the whole of the neck and the upper part of 
the body of the sac were absorbed, but the remaining portion of its body 
and fundus were entire, and formed a bag in the scrotum in front of 
the tunica vaginalis. 

II. THE PRECISE SITUATION TO WHICH THE TRUSS SHOULD BE APPLIED. 

Since the immediate object which the surgeon desires to accomplish 
by the pressure of the truss is, to prevent a return of the hernia, and 
the ultimate object, to induce some of the various changes already de- 
scribed, by which the tendency to its recurrence may be removed, it 
must be evident that the precise part to which the pressure should be 
applied is, that where the hernia first quits the abdomen. This point 
will vary in the different forms of hernia, and will afterwards be ex- 
plained; but meanwhile it may be stated that before the various 
changes in the sac, and in the opening by which it quits the abdomen, 
were clearly understood, by which changes a complete cure of hernia is 
effected, a very common error which prevailed was, to apply the truss 
too low instead of exactly over the opening ; and in consequence, the 
advantages of the truss were often not obtained, and moreover various 
inconveniences, which will hereafter be described, were frequently pro- 
duced. 

III. THE LENGTH OF TIME A TRUSS SHOULD BE WORN. 

As the prospect of a complete cure is very different at the different 
periods of life, it being almost a matter of certainty in young persons, 
occasionally met with in adults, and not to be expected in elderly per- 
sons, there will be a corresponding difference in the length of time that 
the truss must be worn, as well as in the object of wearing it ; the ob- 
ject being at one period merely preventive or palliative treatment, at 
others palliative treatment and radical cure. In young persons a com- 
plete cure is often effected in less than twelve months, in adults seldom 
under two years at least, and in old persons it is not to be expected. 
In regard to the time a truss should be worn, Sir Astley Cooper re- 
marks, "You wiirbe asked by the patient when you have applied the 
truss, how long he is to wear it ; tell him to wear it at least two years. 
He will then ask you whether he is likely to be cured at the end of 
that time ; your answer must be that this must depend upon his age. 
A young person is generally cured at the end of two years, but it will 



454 HERNIA. 

be advisable for him to continue to use the truss for three years. If 
the person be not young, there is not much hope of effecting the cure 
of hernia by wearing a truss." 

The truss should be constantly worn, not only during the day, but 
also during the night, because although the probability of a recurrence 
of the hernia is by no means great in the recumbent posture, yet it 
might be induced by a cough, or any sudden change in the posture of 
the body in bed, and then the cure would require to be commenced 
anew from that period. It ought also to be kept in mind that the 
recurrence of the hernia, after the use of the truss has been commenced, 
is attended with more risk than before, because if thickening about the 
neck of the sac or around it has commenced, the hernia is more likely 
to be irreducible from being surrounded by firmer textures. According 
to some of the best surgical authorities upon this subject, the only ex- 
ceptions that should be made to the constant use of the truss are, when 
it is first applied, and before it is to be laid aside, when it is believed 
that a complete cure has been effected. When first applied, the truss 
frequently gives rise to irritation, and heat of the skin, with inconve- 
nience and discomfort from pressure and restraint ; and until these 
unpleasant sensations wear off, which will usually be in a week or two, 
it may be discontinued during the night, but the patient should even 
then be careful not to remove it until he is in the horizontal posture, 
and he ought again to apply it before raising himself from that position. 
And when it is believed that the cure is complete, the truss may be 
discontinued at night, before it is entirely laid aside. For some time 
after the daily use of the truss is discontinued, it is a judicious precau- 
tion to wear it whenever the body is more than usually relaxed. When 
the danger of a recurrence of the hernia is greater, or during any un- 
usual exertion, and during the whole period of wearing the truss, it is 
proper, on making any violent movement or effort, to afford a degree of 
support by the hand over the pad of the truss. When it is believed 
that the cure is complete, the surgeon should make a very careful exa- 
mination of the part where the hernia came out from the abdomen ; and 
before he sanctions the discontinuance of the truss, he should endeavour 
to ascertain that no swelling can be felt, and that during coughing, or 
any exertion of the muscles of the abdomen, there is no sensation of a 
hernia striking against the finger when applied to the opening. 

IV. THE CHIEF SOURCES OF IRRITATION AND INCONVENIENCE FROM 
WEARING A TRUSS. 

The chief inconveniences from the use of a truss arise for the most 
part from its being too strong, or from the pad being placed in an im- 
proper situation, hence the necessity of selecting a truss of the proper 
strength and length for a patient. It should be strong enough to 
prevent any recurrence of the hernia, but not to cause any painful 
irritation of the soft parts. Labouring people and those who are re- 
quired to use great bodily exertion need stronger trusses than others. 
The length of the truss is also a matter of great importance, not only 
that the pad may rest on the precise spot where the hernia came out 
from the abdomen, but also that it may not rest upon the side of the 



HERNIA. 455 

pubes, the result of which is apt to be irritation of the soft parts from 
pressure between the bone and the truss, and swelling of the testicle 
from compression of the veins of the cord. 

IRREDUCIBLE HERNIA. 

Definition. — A hernia is said to be irreducible, when it suffers no 
constriction, and yet cannot be returned into the abdomen. For facili- 
tating the description of this form of the disease, it may be useful to 
attend successively to the causes which prevent reduction, to the dangers 
and inconveniences which may arise from irreducible hernia, and to the 
treatment. 

Causes which prevent Reduction. — First. A frequent cause which 
prevents reduction, is the bulk of the protruded parts in relation to the 
opening through which they would have to return. The bulk is some- 
times, and especially in neglected cases where means have not been used 
to give a degree of support, owing to the quantity of parts which have 
come out of the abdomen, but more frequently to the enlargement or 
growth of the hernial contents. The omentum and mesentery are the 
parts which when protruded present the impediment to reduction from 
growth ; and their increase is occasioned mostly by the deposition of 
fat in the portions of these tissues, external to the opening through 
which they came out from the abdomen. Where they are embraced by 
the opening, the pressure prevents enlargement in that situation ; but 
from the yielding nature of the textures external to the opening, the 
increase of volume is often very considerable. In old irreducible hernige 
the omentum is not unfrequently found to be affected with thickening 
and hardening, caused by the effusion and organization of coagulable 
lymph. 

Second. Constriction of the neck of the hernial sac is occasionally 
the obstacle to reduction. That this condition of the neck of the sac 
sometimes exists to an extent sufficient to constitute, without an opera- 
tion, an insuperable impediment to reduction, is a point regarding which 
surgeons are agreed, numerous instances having been recorded by the 
great surgical authorities of this and other countries, and examples 
occurring frequently in the practice of many surgeons. Not only is the 
sac necessarily narrower at the neck than in any other situation, from 
the manner in which it is embraced by the surrounding textures, but it 
is liable to be still further diminished by changes without and within 
the sac, and in the nature of the sac itself. For a minute description 
of these changes, the conditions under which they most frequently take 
place, and the nature of the action by which they are produced, I beg 
to refer to the section on the anatomy of the hernial sac, and the seats 
of stricture in the. different species of hernia ; and meanwhile, I shall 
only remark that thickening and induration of the cellular tissue around 
the sac, effusion and organization of lymph without, and often also 
within the sac, and" a thickened and indurated state of the sac itself, 
are the principal conditions which, separately or in various degrees of 
combination, diminish the canal of the sac, so as to prevent reduction. 
There can be very little doubt, that these changes are produced by the 
pressure on the neck of the sac, causing a slight degree of inflammation, 



456 HERNIA. 

which terminates in effusion of coagulable lymph, and that the lymph 
afterwards becoming organized, occasions the constriction. Although 
constriction, when sufficient to render a hernia irreducible, is usually, 
yet it is not invariably, at the neck of the hernial sac ; a fact of little 
practical moment, if a hernia be merely irreducible, but of the greatest 
importance, if it be strangulated and require an operation, the object of 
the operator being to divide the constriction in order to relieve the 
symptoms of strangulation. 

Third. Adhesions of the protruded parts to the hernial sac often 
constitute the impediment to reduction. Of these adhesions there are 
three varieties ; — 

1. The protruded parts sometimes adhere to the sac through the me- 
dium of a layer of coagulable lymph. This form was described by 
Scarpa as the gelatinous or glutinous adhesion, and as this is a condition 
of parts which very quickly takes place, the surgeon should endeavour 
to reduce the hernia as soon as possible, in order to prevent the slight 
inflammation which gives rise to the effusion. 

2. Adhesions sometimes assume a membranous or filamentous appear- 
ance, varying greatly both in the number and length of the filaments, — 
in the number, from a single band to several, and in length, from two 
or three lines to an inch and upwards as a general rule. Adhesions of 
this form are found only connecting movable parts with each other, as 
the intestine with the hernial sac, or with the omentum ; and they are 
precisely similar to the bands we often find between serous surfaces in 
other parts of the body. They are produced by the effusion of coagu- 
lable lymph, which ultimately becomes organized — therein differing from 
the last-mentioned form — and which is drawn out into bands or filaments 
by the movements of the intestines. This accounts for their being 
found chiefly connecting movable parts with each other, and for their 
being more frequent in the body and fundus of the sac than at its neck 
or mouth, where the parts are in a more confined space, and have less 
motion. This is now the almost universally received opinion of the ori- 
gin of the membranous or filamentous adhesions. A different theory,' 
however, is held by Scarpa, who says : — "I am of opinion that the for- 
mation of this filamentous or membranous adhesion is constantly pre- 
ceded by a slight attack of adhesive inflammation, with immediate union 
of the intestine or of the omentum with the hernial sac; a superficial 
union indeed, but in progress of time — especially from the intestine 
separating gradually from the hernial sac by its own vermicular action, 
by the considerable distension produced in it by the interruption of the 
faeces, by its proper contractile power, and that of the mesentery, by the 
interposition of serum always collecting in the sac — the thin covering 
of the intestine, corresponding to the points of superficial adhesion with 
the hernial sac, yields and elongates, so as to form at last one or more 
filaments, bridles, or membranes interposed between the intestine and 
the sac of the hernia." In short, Scarpa's opinion was, that they are 
formed of elongations of portions of the serous coat of the intestine. 

3. The third form of adhesion, which usually receives the name of 
the fleshy, is like the gelatinous and membranous, in being the result of 
adhesive inflammation, but differs from them, inasmuch as the union is 



HERNIA. 457 

close, firm, and deep, so that the protruded parts and the sac cannot be 
separated from each other, but form a solid mass, the vessels of which 
are continuous. 

In a case of strangulated hernia, the subject of operation, this form 
of adhesion demands a very different method of procedure from the 
gelatinous or membranous, as will be explained in the section on that 
subject. This species of adhesion is very frequently met with between 
omentum and hernial sac, and then is generally at the body and fundus 
of the sac ; but when it is found between intestine and sac, which is a 
very rare occurrence, it is usually at the neck. 

Scarpa has described this form under the name of the unnatural 
fleshy, to distinguish it from what he calls the natural fleshy, which is 
of an entirely different character, and will be afterwards described. 

The three forms of adhesion agree with each other in being caused by in- 
flammation, and in being attended with effusion of lymph ; but they differ, 
inasmuch as the lymph in the first form is not organized ; in the second, 
it is organized and elongated into bands or filaments ; and, in the third, 
although organized, it is not elongated, but effused tetween the sac and 
protruded organs, and between the tissues of these parts, so as to con- 
vert them into a solid inseparable mass, the vessels of which are conti- 
nuous. 

Fourth. Adhesion of the protruded parts to each other often forms 
the impediment to reduction. The parts which form a hernia often 
glide down separately, and to a great extent, into the sac, and after- 
wards by pressure and various accidental causes, become adherent to 
each other, and cannot in mass be returned through the opening by 
which they separately left the abdomen. 

Fifth. Membranous bands across the sac constitute an insuperable 
obstacle to reduction. In reference to these bands, Sir Astley Cooper 
remarks, — "They appear to be produced in the following manner: 
during the reducible state of the hernia, inflammation takes place, both 
in the contained parts and in the inner surface of the sac ; but by 
using proper means, the protruded parts are reduced, and the sides of 
the sac collapse and adhere together. However, while the adhesions 
are still recent, a fresh descent takes place from the abdomen, and the 
hernial contents again disunite the surface of the sac everywhere, 
except at the points of union of the inflamed parts, the cementing 
lymph of which instead of bursting asunder, elongates with the fresh 
pressure, and forms those membranous bands, which are seen passing 
from one side of the sac to the other. Between these the intestine and 
omentum get entangled, a circumstance which adds so much to the diffi- 
culty of reduction, as to make it, in general, considered as impracticable ; 
but unless the hernial contents themselves adhere, there appears no 
reason why the means already pointed out, may not here also prove 
successful. After all, there is scarcely a possibility of detecting by the 
feel, this variety of the disease in the living subject." 

Sixth. The obstacle to reduction is sometimes furnished by the natural 
means of connexion between the intestine before its descent, and the 
peritoneum lining the surrounding part of the abdomen. It is of the 
greatest importance that the surgeon should have clear and distinct 



458 HERNIA. 

ideas of this condition of a hernia, for if it be not understood, and if 
an irreducible hernia of this kind should become strangulated and 
require an operation, the most dangerous errors may be committed. 

Scarpa gave an exceedingly clear and full explanation of this condi- 
tion of a hernia ; it has also been described by Pelletan, Cloquet, and 
Hesselbach, and with great distinctness by Mr. Lawrence. Pott, in 
two parts of his valuable work, refers to the difficulty of reducing 
certain hernise, where there is reason to believe the obstacles to reduc- 
tion arose from this condition; but from the manner in which he 
expresses himself, it is not evident that he understood the real cause of 
the impediment. The natural means of connexion of the hernia to the 
surrounding parts, may form the obstacle to reduction on the right side, 
if the hernia be formed of the ccecum, or head of the colon ; or on the 
left, if it be formed of the sigmoid flexure of the colon. These divisions 
of the alimentary canal are completely covered by peritoneum, laterally 
and anteriorly, but are destitute of a peritoneal covering behind ; and 
the peritoneum is reflected from their lateral aspects to the parietes of 
the abdomen in the ilio-lumbar regions, with which the parietes is con- 
nected by loose cellular tissue, capable of great dilatation. The natural 
means of connexion of these divisions of the alimentary canal with the 
parietes, are short, and formed of peritoneum, between that portion of 
it which furnishes a serous coat to the intestines, and that which lines 
the walls of the abdomen. If these portions of alimentary canal descend 
to form a hernia, they will drag along with them the part of the perito- 
neum which naturally lines the parietes of the ilio-lumbar region, to form 
the hernial sac ; and if the hernial sac descend into the scrotum, and 
there form adhesions to the surrounding parts, the portions of perito- 
neum which, within the abdomen, preserved the intestine in its natural 
relations to the walls of the abdomen, will now retain it in the sac; and, 
as through the medium of these portions, the hernial sac and serous 
coat of the portion of intestine which forms the hernia, are continu- 
ous with each other, it is evident that the reduction must be impracti- 
cable. It is as impracticable, under these circumstances, to return the 
intestine as it would be to return the testicle into the abdomen ; the 
intestine draws peritoneum along with it to form a hernial sac, and the 
testicle draws peritoneum to form tunica vaginalis ; and the serous coat 
of the intestine has the same relation to the hernial sac, as the tunica 
vaginalis reflexa has to the tunica vaginalis propria. 

Such a hernia, when it becomes strangulated, and an operation is to 
be performed, requires a particular method of treatment, which will 
afterwards be explained. 

DANGERS AND CONSEQUENCES WHICH MAY RESULT FROM 
IRREDUCIBLE HERNLE. 

The chief dangers which may result from irreducible herniae are, 
inflammation of the hernia, laceration or injury of the intestine from 
violence, extreme inconvenience from its size, and strangulation. 

The chief source of anxiety, however, in irreducible hernia is the risk 
of its becoming strangulated — a state in which the life of the patient is 
placed in the most imminent danger. The symptoms of this state, the 



HERNIA. 459 

condition on which they depend, and the treatment requisite, will be 
explained under the head of Strangulated Hernia. 

Irreducible hernise, even when left to themselves, do not always attain 
a great size ; and sometimes they give rise to no inconvenience whatever, 
beyond a sense of weight and fulness in the parts aiFected. Sometimes 
they render the subjects of them liable to occasional colic pains, and 
derangement of the digestive organs, but in other instances these symp- 
toms do not present themselves. 

TREATMENT OF IRREDUCIBLE HERNIA. 

From what has been stated of the causes which render hernise irredu- 
cible, and of the dangers which may result from them, the indications 
and rationale of treatment may be very easily understood. In every 
case the diet should be carefully attended to, and everything avoided 
which would be apt to produce derangement of the digestive system, and 
the bowels should be preserved free from constipation, as a loaded con- 
dition of the alimentary canal would, by increasing the distension, be 
likely to cause an increase of the protrusion ; in short, the intestinal 
canal should, as much as possible, be preserved in a regular and natural 
state. 

The hernial tumour should be carefully defended from any injury by 
external violence, and the greatest precaution taken to avoid every kind 
of exertion, by which an addition might be made to the protrusion, or 
the parts already protruded be injured, or their condition in any way 
changed. To retard the growth of the hernia, and to diminish the pro- 
bability of its proceeding to such a size as to cause inconvenience, the 
tumour should if possible, be supported by means of a suspensory ban- 
dage ; and if it has already attained great size, by a suspensory laced 
bag, by which an increase of the hernia is sometimes prevented, and its 
size diminished by absorption. These precautions may be said to con- 
stitute the proper treatment of an irreducible hernia ; and however 
little inconvenience a hernia may occasion, they ought never to be disre- 
garded. 

As greater risk attends an irreducible than a reducible hernia, various 
means have been proposed and adopted for removing the obstacles which 
oppose reduction. 

Of these the principal are, 

1. The diminution of the size of the hernia by producing emaciation. 

2. The absorption of part of the hernia by the application of pressure. 

3. The application of cold ; and 

4. An operation. 

1. Fabricius Hildanus records an instance of a man who was cured 
of a hernia of twenty years' standing, by six months' confinement to 
bed ; and Arnaud gives an. account of several cases, in which very large 
hernise had entirely disappeared after the patients had become much 
emaciated by long confinement with tedious illnesses. Impressed by 
these instances, Arnaud endeavoured to effect radical cures in certain 
cases by an imitation of this process of Nature. The means he employed 
were, confinement to bed, restriction of diet, occasional venesection, and 
the frequent exhibition of purgatives and clysters ; and in numerous 



460 HERNIA. 

instances he succeeded in accomplishing reduction. The late Mr. Hey 
of Leeds reduced several hernias by the same means, and states that 
usually the cure occupied six weeks, but in one instance it was accom- 
plished in a week. 

While a hernia is merely a source of present inconvenience, and little 
apprehension is experienced of what may be its future consequences, 
few patients will submit to a method of treatment which is attended 
with so much discomfort, and requires so much self-denial ; besides 
which, to a patient of advanced age, this method might give rise to 
serious results, and in such circumstances, therefore, a prudent practi- 
tioner would hesitate at recommending its adoption. But the great 
objection to this method of treatment is, that it cannot prove of any 
service whenever the obstacle to reduction is adhesion in any of its 
different forms ; and since there is no criterion for distinguishing where 
adhesions do or do not exist, it is almost impossible in any case for a 
surgeon to assure his patient that it will certainly succeed. The cases 
in which this treatment is likely to be attended with a favourable result 
are, those of omental hernia, in which enlargement of omentum from 
accumulation of fat forms the impediment to reduction. 

2. Pressure is another means which has been employed in cases of 
irreducible hernia, and it has been recommended in cases where the 
impediment to reduction is enlargement of the omentum from accumu- 
lation of fat ; but for various reasons which need not be mentioned, it 
appears to be extremely injudicious to venture on this treatment. 

3. By the application of cold, hernias of considerable standing have 
been returned. 

On this subject Sir Astley Cooper, who proposed this method of 
treatment, makes the following remarks : " In some cases the applica- 
tion of ice occasionally procures the return of a hernia which appeared 
irreducible. I was asked by a physician to examine a hernia which had 
come down about a fortnight before, and had ever since resisted all 
attempts at reduction, without being painful. I found it was omental 
hernia, and ordered ice to be kept upon the tumour for a considerable 
time. In twenty-four hours it was so much diminished as to encourage 
a perseverance in the plan, and in four days the hernia was entirely 
removed. 

" Mr. G-., a surgeon in the East India service, called to show me an 
omental hernia on the right side, which, though not painful, gave him 
some anxiety, as it could not be returned, and he was apprehensive of 
its becoming strangulated at some future time. I ordered him to bed, 
and put him on the same plan as in the former case, which produced a 
very gradual diminution of the tumour, and, at the end of five days, its 
entire removal. It appeared to me in both cases, that the good effects 
attending the use of the ice, were owing to a consequent contraction of 
the scrotum, which thus performed the office of a strong and permanent 
compression of the tumour." 

During the spring of 1841, I was very much gratified with the effect 
of the application of ice, in the case of a person named Kelly, a butcher, 
then sixty-six years of age. For many years he had been annoyed with 
a reducible inguinal hernia on the right side, for which he required to 



HERNIA. 461 

wear a truss. He always succeeded in returning the hernia without 
any assistance, until about two weeks before I saw him, when it came 
down, he said, to a greater extent than on any former occasion ; but 
for twelve days it was unattended with pain or any inconvenience, 
beyond a sense of weight or weakness of the affected part. After it had 
been down for twelve days, it became, in consequence of some over- 
exertion, painful and tight ; and when I saw him, two days after the 
commencement of the pain, and two weeks after the descent of the hernia, 
I found him labouring under the ordinary symptoms of strangulation, 
which, according to his report, had been much more urgent for the eight 
hours preceding my visit, than before. The hernia extended down to 
the middle of the scrotum ; and, from the examination, I felt fully 
satisfied (as did also a medical friend who likewise saw the case) that 
the hernia consisted partly of omentum and partly of intestine. I 
instituted the ordinary treatment for strangulation for five or six hours, 
and thought I should be obliged to have recourse to an operation ; but 
on making a second careful attempt at reduction by means of the taxis, 
a small part returned very suddenly, and almost immediately he felt 
relieved, both from the local and general symptoms, and the bowels 
were soon opened ; but still it appeared impossible to return any more 
of the hernia. I then ordered ice to be kept over the hernia, and in the 
course of thirty hours from its first application, the hernia entirely dis- 
appeared, and the use of the truss was then resumed. 

I have often successfully used ice, in conjunction with other remedies, 
in reducing hernia in different states ; but in the present instance, the 
return of the part which remained after the subsidence of the symptoms 
of strangulation, when the case presented the characters of a simple 
irreducible hernia, must have been owing solely to the application of 
ice, as no other means of reduction were used at the same time. From 
all I have been able to ascertain from recorded experience, from what 
I have been told in conversation by others, and from what I have seen 
in my own practice, my decided impression is, that it is only in hernia 
of very short standing that the application of ice proves to be of ser- 
vice ; and the same conclusion is suggested, independently of observa- 
tion and experience, by our knowledge that the cause which prevents 
the reduction of hernia of long standing, is frequently one or other of 
the forms of adhesions already described, and that on these the applica- 
tion of cold by means of ice could produce no beneficial impression. 

4. An operation is the only practicable method of accomplishing re- 
duction, when adhesions are the impediment ; and unfortunately, in 
most hernise of long standing adhesions do exist. 

It may be laid down as a general rule, that as an irreducible hernia 
is only a source of inconvenience, and exposes the patient merely to 
the risk of being thrown into a hazardous situation by its becoming 
strangulated, or giving rise to some of the consequences described in a 
former section, the surgeon is not justified in performing an operation 
which puts the life of the patient into immediate and great danger ; on 
the contrary, it is his duty to advise the patient to be satisfied with 
such palliation of his complaint as may be obtained from the means 
which have been already pointed out. Still, operations have been per- 



462 HERNIA. 

formed ; but it appears from recorded experience that they have gene- 
rally proved fatal. The great size which an irreducible hernia often 
presents, the extent of adhesions, and the consequent danger of the dis- 
section, and great risk of inflammation, are considerations which would 
deter a prudent surgeon from venturing on an operation, unless some 
very distressing symptoms should demand it. On this subject, Mr. 
Lawrence, in his valuable work on hernia, remarks : — " Yet an objection 
must be made to the general rule of not operating in irreducible hernise, 
in behalf of those instances where the tumour occasions such essential 
inconvenience and suffering to the patient, as to induce him, when the 
dangers he incurs have been fully represented, to submit to the opera- 
tion. Such was the case of the celebrated Zimmerman ; the omentum 
adhered by a single filament to the testicle ; when the former was re- 
placed, the latter ascended with it, and experienced very painful pres- 
sure from the ring ; if the parts were allowed to protrude again, a por- 
tion of intestine generally followed, was pressed on by the ring, and 
occasioned a fear of strangulation. The pressure of a truss occasioned 
such severe suffering, that it could not be borne. In a patient on whom 
Mr. Abernethy operated, an adherent epiplocele gave rise to frequent 
protrusions of the intestine, which were highly distressing. A particular 
source of danger and inconvenience existed in both these cases, and ad- 
mitted of no remedy but the operation." 

STRANGULATED HERNIA. 

A hernia is said to be strangulated, when the protruded parts expe- 
rience such a degree of pressure as not only prevents their return, but 
also, by compressing their blood-vessels, disturbs or in a measure sus- 
pends or impedes the circulation in them. This condition very speedily 
produces inflammation in the protruded parts, which extends itself from 
thence to the parts within the abdomen. 

Symptoms. — There is pain in the swelling, beginning about the neck, 
or being at first most considerable there, and propagating itself gradu- 
ally over the swelling in the direction from the abdomen. The swelling 
becomes tense, and there is for some time, tenderness on pressure, after- 
wards pain on pressure, in some instances very acute. In some exam- 
ples there are heat and redness. Such are in many cases the local 
symptoms ; and if death do not very speedily take place, they occasion- 
ally change for a short time before its approach, the swelling becoming 
flaccid, the pain and tenderness on pressure wearing off, and crepitation 
being perceptible on examination : — such symptoms denoting the pre- 
sence of gangrene. 

The symptoms connected with the alimentary canal are, eructations, 
nausea, vomiting, and insuperable constipation of the bowels. At a very 
early period the patient is troubled with eructations, followed by nausea 
and vomiting. The contents of the stomach are first vomited, and after- 
wards, in consequence of inverted peristaltic motion, those of the canal 
between the stomach and the seat of the stricture. Bilious matter is 
brought up in large quantities, and the contents of the small intestine, 
and even of part of the large intestine, if any portion of that division of 
the alimentary canal should be placed higher up than the part included 



HERNIA. 463 

in the stricture. When the contents of the large intestine are brought 
up, the vomiting is called stercoraceous. The insuperable constipation 
is a striking symptom. It may be possible by means of clysters to 
wash out the portion of canal which is below the hernia ; but it is im- 
possible while the strangulation remains, to procure any evacuation from 
the part of the intestine above the hernia ; and this is not owing to a 
mechanical obstruction offered by the stricture, for the constipation is 
insuperable when the stricture only diminishes the calibre of the intes- 
tine, as well as when it includes an entire fold ; and it is insurmountable 
in cases of omental hernia, after the inflammation has extended to the 
intestine. The constipation is owing to the same cause as in enteritis 
or ileus, of which strangulated hernia is an example, though differing 
from ordinary cases in being produced by a mechanical cause. 

There are some symptoms connected with the abdomen, which are 
quite characteristic of strangulation ; namely, a sensation as if a cord 
were tied tightly round the upper part of the abdomen, twisting pains 
about the umbilicus, and pain diffused over the whole abdomen, but gene- 
rally more considerable from the seat of the hernia to the umbilicus. The 
abdomen after a certain time becomes tense, and, as the disease ad- 
vances, tender and painful on being pressed, or stretched; and, therefore, 
the patient lies quite still, with the limbs drawn up to relax the abdomi- 
nal parietes. After a time, hiccough comes on, and the belly becomes 
tympanitic. The tongue is white and dry, the countenance pale, anx- 
ious, collapsed, and expressive of great suffering ; the pulse, which from 
the beginning is small and hard, becomes very quick, and extremely small 
and thready ; there is great sense of feebleness, the extremities ultimate- 
ly become cold, and the surface of the body covered over with a clammy 
perspiration. When gangrene has actually taken place, the patient may 
experience a sudden and complete relief from all pain and tenderness in 
the swelling or abdomen ; the former may feel emphysematous, a sure 
sign of gangrenous mischief; it may feel flaccid, or even return on pres- 
sure ; the abdomen may become free from all tenderness on pressure, 
but it still remains tense ; the patient may feel himself relieved from all 
suffering, and in many instances even a few minutes before death, patients 
have expressed themselves as perfectly confident of recovery ; but the 
pulse is extremely feeble, and usually in this state irregular ; the clammy 
perspiration remains, and death very soon closes the scene. 

Such are, generally, the symptoms of strangulation ; but they are not 
in all cases of equal intensity or rapidity. When the patient is not ad- 
vanced in life, when the hernia is intestinal and recent, and when 
the stricture is tight, the symptoms are alarmingly intense, and present 
the assemblage already described. In elderly persons, and more espe- 
cially when the hernia is of long standing, the mouth of the sac proba- 
bly being widened by the distension occasioned by the protruded parts, 
the symptoms are usually less urgent and slower in their progress, and 
for some time their appearance seems to indicate that they are to be 
referred to obstruction of the alimentary canal rather than to inflamma- 
tion. There can be very little doubt that in such cases, accumulation of 
faecal matter from torpor of the intestine is frequently the cause of dis- 
comfort, and that the inflammatory process is a consequence arising 
from it. When the hernia is omental, the symptoms of strangulation 



464 HERNIA. 

are less violent and slower in progress than when it is intestinal ; the 
pain and sense of constriction in the tumour are comparatively incon- 
siderable ; the pain and tenderness of the abdomen not so urgent ; the 
vomiting not so frequent ; and the constipation not by any means so 
very obstinate ; so that the bowels may be moved by enemata until the 
inflammation has reached the intestine, when, as in a case of ileus, it 
becomes insuperable. In some cases, but they certainly are extremely 
few, inflammation in the hernia is the cause of strangulation ; but in by 
far the greater number of examples inflammation is the consequence of 
the constriction. Under all circumstances, the symptoms of strangula- 
tion furnish ground for the greatest alarm. Although cases are often 
known to go on for several days, others have terminated fatally in a 
very short time. The works of Larrey, Pott, Cooper, Hey, Wilmer, 
and others, contain records of cases in which strangulation has been fol- 
lowed by death in less than twenty-four hours. Sir Astley Cooper al- 
ludes to a case in which death took place in eight hours after the 
occurrence of strangulation, and Larrey met with two examples in which 
only two hours elapsed between the occurrence of strangulation, and 
the death of the patient. Strangulated hernia has the same general 
symptoms as ileus and intus-susception, and in addition to these it has 
its own peculiar local symptoms. The presence of the symptoms above 
described should always lead to a careful examination of the usual sites 
of hernial protrusion, and the absence of local swelling in such cases 
warrants the conclusion that they depend upon a cause which is intra- 
abdominal. Conditions, however, may exist requiring great care to form 
a correct diagnosis, namely, the coexistence of ileus with an irreducible 
hernia, not strangulated, or, the presence of ileus with an ambiguous 
tumour at any of the ordinary sites of hernial protrusions. The history 
of the symptoms, the absence of a sense of tension or of pain in the 
swelling, or of any alteration of the symptoms connected with the tu- 
mour, and there being little or no tenderness on pressure, render it ex- 
tremely probable that the symptoms are independent of the local affec- 
tion, or that the latter has no casual relation to them. The proper view 
to be taken of a strangulated hernia, I conceive, is, that it is a species 
of ileus produced by a mechanical cause. 

Treatment. — Strangulation being caused by compression of the pro- 
truded parts, an indication of paramount importance is to relieve them 
from the pressure as speedily as possible. With that view, replacement 
should in most cases be attempted by a certain manual process, techni- 
cally called the operation of the taxis. To diminish the tension of the 
opening, through which the parts are protruded, the patient should be 
placed in the recumbent posture, with the trunk bent a little forward, 
and the thigh of the affected side raised upwards and inwards. With 
the fore-finger and thumb of one hand, the tumour should be embraced 
at its neck, and replacement attempted by a kneading or pinching 
movement at that part, while with the other hand the tumour should be 
subjected to general pressure ; the object being, not to push back the 
hernial contents in mass, but to knead up the tumour, bit by bit ; and 
in doing this, it is necessary to observe the course which the protruded 
parts must have taken, that the direction of the pressure may be accom- 



HERNIA. 465 

moclated to it. Before attempting to press up the tumour, it is often 
advantageous to draw the hernia downwards, as if the object were to 
draw the hernial contents farther from the abdomen. By this proceed- 
ing, the neck is rendered straight, and an obstacle, offered by the hernia 
being much swollen on the aspect of the stricture farthest removed 
from the abdomen, is diminished, so that the taxis can be employed 
under more favourable circumstances. The taxis should be employed 
gently, steadily, and cautiously, without any force or violent effort, and 
even when used most prudently, it should not be continued for more 
than eight or ten minutes, nor should it be persevered with after it has 
been ascertained that there is no reasonable prospect of its employment 
being successful. 

In some cases of strangulation, it would be extremely injudicious to 
use the taxis at all, or any other means for accomplishing reduction ; 
and in a very few others, it ought not to be employed until the state of 
the tumour has been changed by appropriate treatment. To the former 
class of cases belong those in which the hernia has become gangrenous, 
or in which there is reason to believe that the intestine has become so 
much softened by inflammation as to be in danger of giving way if re- 
turned into the abdomen. In such circumstances, fsecal extravasation 
and death would be the consequences of returning the hernia. The 
proper treatment of such cases will be explained, when describing the 
operation for strangulated hernia. The cases in which it is not prudent 
to use the taxis are by no means numerous. In reference to this prac- 
tical point, it is important to remember what has been stated in the de- 
scription of the symptoms of strangulation, namely, that although in 
the great majority of cases, inflammation is the result of the strangula- 
tion, yet in some exceedingly rare cases, the reverse takes place ; — the 
hernia becoming inflamed and swollen, and in consequence, embraced so 
tightly by the surrounding textures, that its circulation is impeded, and 
strangulation produced. The prudent procedure is, to endeavour by 
the application of leeches around the hernia, by general depletion if 
necessary, by cold applications and other antiphlogistic remedies, to 
subdue the inflammation ; and the cause having been removed or modi- 
fied, the taxis may then be employed, not only with safety, but also with 
a more reasonable prospect of success. If symptoms be urgent, how- 
ever, an operation should be resorted to for the purpose of removing the 
pressure. The direction in which the hernia should be pressed, during 
the operation of the taxis, varies in the different species of hernia. Fur- 
ther information on this subject will be given in a subsequent chapter. 

In the event of the taxis not being successful, recourse should be had 
to some of the various means, called auxiliaries to the taxis, and then 
the taxis should be tried a second time. Of these means, the most use- 
ful are bloodletting, the warm bath, the very abundant application of 
cold, enemata, and chloroform. 

Bloodletting is no doubt a valuable auxiliary in certain cases, espe- 
cially when the symptoms are very acute, and the hernia small, when 
depression has not come on to a great extent, and when the patient is 
not at an advanced period of life. It favours reduction, partly perhaps 
by diminishing the bulk of the hernial contents, though its effect in that 

30 



466 HERNIA. 

way must be very slight ; but principally, and indeed almost entirely, 
by producing relaxation, and thereby increasing the size of the opening 
through which the parts have to be returned. Such being the principle 
of its usefulness, it will be desirable to produce fainting by the bleeding, 
and with this view, the head and trunk of the patient should be raised 
to the erect position during the bleeding, and the blood should be taken 
from a large opening. When fainting is induced, the taxis should be 
used a second time. Bloodletting is also advantageous, by diminishing 
the tendency to inflammation after reduction. 

The warm bath is useful on the same principle as bloodletting, and 
in the same class of cases ; and if the two auxiliaries can be used to- 
gether, that is, if the patient be bled to faintness in the warm bath, the 
taxis may then be employed under very favourable circumstances. Un- 
less the bath be sufficiently warm to induce faintness, little or no benefit 
will result from its use. Delay, however, being so dangerous, this is a 
remedy which cannot always be employed in private practice, on account 
of the time which would often be required for its preparation. 

The abundant application of cold over the hernia is a valuable auxi- 
liary to the taxis, and in various instances it has produced reduction with- 
out the taxis. The application must be continued for a considerable 
time, otherwise it can have no effect. Pounded ice enclosed in a blad- 
der, is one very convenient way of applying cold, and another is by a 
mixture of muriate of potash and muriate of ammonia. The cold dimi- 
nishes the bulk of the tumour, and also induces a degree of constant 
pressure, by the contraction of the textures covering the hernia. 

Mild enemata are also useful, more especially in cases of large and 
old hernia, when strangulation has been brought on by torpor, and a 
loaded condition of the alimentary canal. The tobacco enema is a very 
powerful remedy, and in the state of extreme relaxation which it brings 
on, the taxis has been used with success. But as in the state of depres- 
sion produced by strangulated hernia, the system has but little power 
to stand out against the lowering effects of this remedy, and as in some 
instances it has appeared to sink under them, I have never ventured to 
employ it, and cannot therefore, from my own observation, say anything 
of its advantages. It appears to me, that this is a remedy which ought 
never to be employed. 

Such, until lately, were the principal auxiliaries to the taxis for ac- 
complishing reduction ; and in regard to their employment it is to be 
remembered, that it is of the utmost importance not to lose time ; that 
in cases where there appears no objection to the use of the taxis, it 
should be employed cautiously, but decidedly and thoroughly ; that in 
the event of its being unsuccessful, such auxiliary remedies should be 
adopted either singly or in combination, as in the particular circum- 
stances of the case seem most advisable, and then the taxis should be 
used a second time ; and if it still be without success, that time should 
not be wasted in the repetition of treatment, which on a full and fair 
trial has failed, but that the surgeon should then at once recommend an 
operation. 

Such were the views entertained, previous to the discovery of the 
properties of chloroform, regarding auxiliaries to the taxis and the proper 



HERNIA. 467 

modes of employing them. The use of chloroform, however, has now 
superseded the necessity of bloodletting, the warm bath, and enemata. 
If the patient be brought well under the influence of chloroform, and if 
on the decided, skilful, and thorough employment of the taxis, the 
hernia cannot be returned, the surgeon may reasonably conclude that 
the constriction is too great to be overcome by any means short of an 
operation. He should therefore spare the patient the danger resulting 
from delay and unnecessary handling, and at once proceed to the opera- 
tion. 

OPERATION FOR STRANGULATED HERNIA. 

There are some peculiarities with regard to the forms of the incisions 
and other important points in the operations for the different species of 
hernia, which will be referred to when the different species are described ; 
but there are some considerations regarding the operation, in general, a 
correct knowledge of which is indispensable. 

Some of the most important of these are — 

1. The circumstances under which it is justifiable or necessary to 
resort to the operation; — 2d. The importance of having recourse to 
operation at an early period, and of abstaining from handling the hernia 
before the operation, more than is necessary for the fair and skilful use 
of the taxis, while the patient is under the influence of the most power- 
ful auxiliary — chloroform; — 3d. The indications which are to be ful- 
filled by the operation ; — 4th. The conditions which render it impossible 
and those which make it improper, to return the hernial contents ; — 5th. 
The mode of procedure in regard to the hernial sac ; — 6th. The anatomy 
and treatment of abnormal or artificial anus ; and 7th. The treatment 
after operation. 

1st. The operation is justifiable and necessary, when the patient has 
been brought fully under the influence of chloroform, and when the 
taxis has been fairly, fully, and skilfully tried, and failed to produce the 
desired effect. The conviction being thus produced that by no other 
means than an operation is there hope of saving the life of the patient, 
it ought to be resorted to as quickly as possible. 

2d. From what has been stated as to the- condition of the parts in 
strangulated hernia, it must be evident that much handling or pressure 
of the hernia must not only give unnecessary pain, but also increase the 
risk of hurrying on the inflammation to results, which, even though the 
operation should be performed, would render it unsafe to return the 
hernial contents. When, therefore, the taxis and other remedies have 
been fairly and skilfully tried, no advantage can, but considerable 
injury may, result from the repetition of treatment already found to be 
unavailing. So deeply was the celebrated Desault impressed with the 
injurious effects of pressure and handling, that he confided in other 
means for accomplishing reduction, and entirely prohibited the taxis in 
cases brought to the Hotel Dieu, until by other means the parts were 
brought into a state in which they could be returned with little diffi- 
culty. 

3d. The indications which are to be fulfilled by operation are two — 
the first, which is essential for the safety of the patient, is the removal 



468 HERNIA. 

of the pressure by division of the stricture, and. the second, which when 
possible and proper, is very desirable, is the return of the hernial con- 
tents. In many instances, especially when the hernia is small, intes- 
tinal, and not of long standing, it returns very suddenly on division of 
the stricture ; in other cases, there are some obstacles apart from the 
stricture which can very easily be removed ; for example, of the four 
varieties of adhesion mentioned, among the causes which render hernia 
irreducible, the soft recent adhesion formed by coagulable lymph, called 
by Scarpa the gelatinous or glutinous adhesion, can be broken down by 
the finger, and the filamentous adhesion can be divided by the knife. 

4th. The principal conditions which render it impossible to return the 
hernial contents after division of the stricture are two forms of adhesion, 
namely, the adhesion by the natural means of connexion, and the close 
organized adhesion, described by Scarpa as the natural and unnatural 
fleshy adhesions. When either of these conditions exists, the stricture 
should be divided, and then the coverings of the hernia should be 
replaced, and proper means taken to heal the wound. Another obstacle 
frequently met with in hernia of great size is, adhesion to each other of 
the different parts forming the hernia. In such cases, if the hernia 
consist of omentum alone, part may be cut away, and the rest returned 
to the mouth of the sac, the hemorrhage being stopped by pinching the 
vessels with a forceps, or including them in fine ligatures, while great 
care is taken not to include any part of omentum along with them. Such 
are the principal conditions which render it impossible to accomplish 
reduction ; the stricture, however, being divided, the principal cause 
of danger is removed. 

There are certain states in which it would be extremely improper to 
attempt reduction, namely, when the hernial contents are gangrenous, 
or when the intestine has given way, from inflammation having gone on 
to gangrene, or when it has been torn, or accidentally wounded in the 
operation. The two last-mentioned conditions can only result from un- 
skilfulness in the mode of procedure ; but should they exist, the hernia 
should not be returned. From what has been stated it will be under- 
stood that, in all cases in which it is possible, if the intestine be sound 
and entire, reduction should be attempted. When the intestine presents 
such an appearance as to render it doubtful whether it can retain its 
vitality, or whether its return may be followed by faecal extravasation, 
the surgeon should content himself with carefully dividing the stricture, 
replacing the coverings, and using proper means for the healing of the 
wound. 

When the intestine is gangrenous, the stricture should be carefully 
divided, but in doing so the greatest caution should be observed not to 
disturb any of the adhesions around the neck of the hernia ; the gan- 
grenous portion should be laid open, its contents cleared out as com- 
pletely as possible, and the coverings replaced ; but no attempts made 
to close up the wound. 

There is some difference of opinion among surgeons as to the most 
prudent method of procedure in regard to the stricture when the intes- 
tine is gangrenous. While they agree as to the propriety of opening 
the intestine and clearing out its contents, some disapprove of any 



HERNIA. 469 

attempt to divide the stricture, as both unnecessary and injudicious — 
unnecessary, inasmuch as they suppose that the evacuation of the intes- 
tinal contents will in every instance sufficiently remove the pressure ; 
and injudicious, from the risk of destroying the adhesions by which the 
intestine is retained at the mouth of the sac, — a condition essential for 
diminishing the danger of fisecal extravasation into the cavity of the 
abdomen. But others recommend a careful division of the stricture, lest 
dangerous pressure should still remain ; and as it is possible to accom- 
plish division without any risk of breaking clown the adhesions round the 
whole of the neck of the sac, this seems the most advisable procedure, 
except when the gastric portion of intestine evidently and freely sends 
down its contents through the wound ; in which case division of stric- 
ture is not so essential. 

Teale, in his admirable work on Hernia, remarks on this subject : 
" Louis maintained that the division of the stricture was not necessary 
for the evacuation of the intestinal canal, after a free incision had been 
made into the gangrenous portion of the intestine;" and Mr. Travers 
has strongly objected to the division of the stricture under these cir- 
cumstances, on the ground of its disturbing the adhesions, and being 
unnecessary for the evacuation of the bowel ; nevertheless, he admits 
that this rule of treatment may have its exceptions. " If," says Mr. 
Travers, " the stricture should still be sufficient to retain the matters, 
which will seldom be the case, a moderate dilatation of it will be re- 
quired." Mr. Lawrence coinciding with Mr. Travers in opinion that 
the division of the stricture is generally unnecessary, states that if the 
stricture be so narrow as to interfere with the discharge, an incision 
must be made to afford the requisite room. To ascertain this point, as 
well as to discover if there be any interior constriction, Mr. Lawrence 
recommends that the end of the little finger, or a female catheter, be 
cautiously introduced into the bowel. Arnaud and Dupuytren divided 
the stricture, when the fseces did not freely escape. The general prac- 
tice of Sir Astley Cooper was to divide the stricture. Mr. Key is of 
opinion " that the danger of disturbing the adhesions has been exagge- 
rated, and states that a director may be passed between the intestine 
and stricture without materially disturbing the adhesions." In all cases 
in which the intestine is not entire, whether from having been purposely 
laid open, or from having given way of itself, or from having been torn 
or cut by unskilful procedure, it should be allowed to remain, so that 
the fseces passing off by the wound, may form an abnormal anus, and 
extravasation into the abdomen be thereby prevented. The wound 
should be left open to facilitate the free discharge of the intestinal con- 
tents, and simple dressings frequently renewed. The anatomy and 
treatment of artificial or abnormal anus will be afterwards explained. 

When omentum forms the hernia, and it is gangrenous, the gangre- 
nous portion may be removed, and the remaining part returned to the 
abdominal aspect of the mouth of the hernial sac. 

These remarks, it is hoped, will be sufficient to point out the proper 
mode of procedure regarding the hernial contents, when the hernia is 
sound and reducible, when it is irreducible, and when it is in any of the 
various conditions in which reduction would be dangerous and improper. 



470 HERNIA. 

5th. The mode of procedure with regard to the hernial sac. 

After the other coverings have been divided by incisions varying ac- 
cording to the situation of the hernia, the sac should be pinched up by 
means of a forceps, where it is seen to be separated from the hernial 
contents by some serous fluid, if such separation be perceptible, or where 
it lies over omentum, if that structure appear to form any part of the 
front of the hernia, and it should then be opened by holding the knife 
in a horizontal position. The point of the fore-finger should then be sent 
up within the sac in front of the hernial contents, and the hernial knife 
carried up flat upon the finger as a director, care being taken not to al- 
low the edge of the knife to touch the hernia. The stricture should then 
be divided through the neck of the hernial sac, the direction of the di- 
vision being from behind forwards. On the return of the hernial con- 
tents the sac is usually allowed to remain in the wound, because in most 
instances it has such adhesions to the surrounding parts as make its 
return impossible. 

It is a question of great importance, in reference to the operation for 
strangulated hernia, which of the two following modes of proceeding in 
regard to the hernial sac is the more advisable ; namely, that of opening 
the sac, and dividing the stricture, from within, or that of dividing the 
stricture and replacing the parts without opening the sac. Of these 
two, technically called the intraperitoneal and extra-peritoneal modes 
of division, the former is that, which, except in a limited number of 
cases, has received the sanction and adoption of most surgical autho- 
rities in these islands. It appears certain that, in the great majority 
of cases, it is by that mode alone, that it is possible to accomplish the 
two grand indications which it is desirable to fulfil by the operation ; 
namely, the removal of the pressure by division of the stricture, and 
the return of the hernia. The fulfilment of the former, namely the 
removal of the pressure by division of the stricture, is essential to the 
safety of the patient: and that of the latter, the return of the hernia, 
exceedingly desirable when practicable and proper. 

With regard to the first indication, when the stricture is external to 
the sac, as is not unusual, it is possible to divide it by adopting either 
mode ; but if formed by the sac, or within it, it is clear, that by intra- 
peritoneal division alone can the more important indication be fulfilled, 
or any good effected. Cases belonging to the latter class are by no 
means of unfrequent occurrence. That the neck of the hernial sac oc- 
casionally constitutes the stricture, is a point regarding which surgeons 
are agreed, instances having been recorded by the great surgical authori- 
ties of this and other countries, and examples occurring frequently in 
the practice of many surgeons. The sac, necessarily narrower at its 
neck than in other parts, is liable io be still further diminished by effu- 
sion and organization of lymph, either on its outer or inner surface, as 
well as by a thickened and indurated state of its own substance, — condi- 
tions which, separately, or in various degrees of combination, diminish 
the canal of the sac. For eighteen years I have availed myself of every 
opportunity of examining the condition of hernial sacs, and from my 
dissections I am led to conclude, that, in hernise of considerable stand- 
ing, thickening of the neck is of frequent occurrence. Although con- 
striction, when sufficient to render a hernia irreducible, is usually at the 



HERNIA. 471 

neck of the sac, yet it is not invariably so. This fact is of little practi- 
cal moment if a hernia be merely irreducible ; but it becomes of the 
greatest importance if it be strangulated, and require an operation, as 
the paramount object of the operation is to divide the constriction, in 
order to relieve the symptoms of strangulation. 

The stricture is occasionally found within the sac. In a very few in- 
stances it has been found to be occasioned by a loop of intestine ; in 
some by a band of omentum ; and in others by a band of lymph effused 
from the serous coat of the intestine, and surrounding and constricting 
it as by a ligature. 

This last-mentioned condition has been described and delineated by 
Sir Astley Cooper. It has also been met with by other surgeons ; and 
not fewer than four cases of it have come under my own observation. 

The first case was that of a female about sixty years of age, of a full 
habit of body, and the subject of a strangulated umbilical rupture. 
Her medical attendant, a surgeon of long standing in Aberdeen, found 
it necessary to have recourse to an operation, and of that I was a wit- 
ness. The hernia returned very suddenly as soon a's the margin of the 
umbilicus was slightly divided ; but the symptoms of strangulation con- 
tinued, and the patient died in ten hours after the operation. I was 
requested to conduct the post-mortem examination ; and, on opening 
the abdomen, found behind the umbilicus a swelling about the size of a 
small orange, formed of intestine, with a neck surrounded by a band of 
lymph, which embraced and constricted the part as by a cord. The 
lymph had been effused from the serous coat of the intestine in conse- 
quence of the inflammation excited by the pressure of the margin of the 
umbilicus. In this case the hernia returned, but without the stricture 
having been divided. 

The second case was that of a female, a patient of my own, about 
the middle period of life, on whom I had occasion, with the assistance 
of Mr. Paterson, surgeon in Aberdeen, to perform the operation for 
strangulated femoral hernia. On carrying up the point of my finger 
between the hernia and the hernial sac to feel for the stricture, I was 
struck with the circumstance, that the tightness of what I supposed to 
be the stricture, bore no ratio to the extreme urgency of the symptoms 
of strangulation, and that, after dividing some of Poupart's ligament, 
by cutting from within the hernial sac, the intestine, on being gently 
pressed, still remained as tense as formerly, and its contents did not 
seem to be moved by the pressure. I therefore examined the neck 
of the hernia with my finger, and perceived a band of lymph keeping 
the part tightly constricted, and, in short, constituting the stricture. I 
gently drew down the intestine, and cut the band in several different 
parts, when the contents of the intestine could be easily made to move 
upwards. On being satisfied that all constriction was removed by 
dividing the band of lymph in various parts, the intestine was returned 
into the abdomen, and the patient recovered without an unfavourable 
symptom. If the hernia had been returnee^ without this band of lymph 
having been discovered and divided, the object of the operation would 
have been unaccomplished. 

The third case was that of a female, about sixty years of age, of a 



472 HERNIA. 

remarkably full habit, and who about two days before I saw her, had 
been seized with symptoms of strangulation. When I first saw her, the 
abdomen was tympanitic to a great degree ; the vomiting was most dis- 
tressing ; the bowels had not been moved for five days, and she had 
every symptom of sinking very rapidly. She stated that she had often 
on previous occasions had attacks of what she believed to be colic, and 
imagined at first that the illness from which she was suffering was only 
a return of that disorder, and, consequently, anticipated a speedy 
recovery. I was also informed that, for a considerable time, she had a 
disagreeable feeling of tenseness in her left groin, though without 
swelling so far as she could perceive ; and that, some hours before I was 
called, while drawing up her limbs in a fit of retching, she felt, to use 
her own expression, as if something had given way in her groin, and 
from that moment was relieved from all feeling of tenseness. The 
symptoms of strangulation, however, continued. I made a most minute 
examination of all the usual seats of hernia, but could detect no symp- 
tom of such a lesion. I requested my colleague, Professor Macrobin, 
to attend the patient along with me, which he did, and he was also 
present at the post-mortem examination. On opening the abdomen, 
there was at its lower part a small tumour of intestine seen, before any 
parts had been disturbed beyond merely turning down the abdominal 
parietes. It was of a livid colour, about the size of a walnut, and with 
a narrow neck, tightly embraced by a band of lymph, by which it was 
so constricted as to make it difficult to pass a probe from that part of 
the intestine which led to the swelling into that which constituted the 
tumour. The intestine was also twisted over itself in form of a loop. 
On examining the femoral canal of the left side, a hernial sac was 
found in it ; and the tumour of intestine had, no doubt, formed a hernia, 
but returned of itself. The stricture, however, formed by a band of 
lymph, still remained. Sir Astley Cooper records a case in which Mr. 
Weston returned a hernia by the taxis without an operation ; but the 
symptoms of strangulation continued, and it was found that the stric- 
ture was caused by a band of lymph which embraced the intestine. In 
the instance of my patient, the hernia returned without any assistance. 
The fourth case was that of a female, whom I had never seen during 
life, but at the post-mortem examination of whose body I was present, 
in consequence of the request of a medical man who had seen her a 
short time before death, and who had also often attended her on pre- 
vious occasions, when in a state of great suffering from disease of the 
womb. The symptoms, I was informed, were those usually induced by 
a strangulated hernia ; but the medical man could not detect any 
swelling in any of the usual seats of hernia. On examining the left 
groin before opening the abdomen, I thought I felt a very small swell- 
ing, which I suspected to be a hernia, and I therefore made a careful 
dissection of the parts in presence of the surgeon, who requested me to 
do so, and of one of my pupils. On cutting through Poupart's liga- 
ment from before backwards, the contents of a small hernial sac returned 
into the abdomen without being touched, and were found to consist of 
intestine strangulated by a band of lymph, embracing the neck of a 
small hernia. The hernia was not much larger than a walnut. If it 



HERNIA. 473 

had been discovered during life, and made the subject of operation, 
there would have been great risk of its returning into the abdomen 
without the real stricture being discovered or divided. 

From what is stated above, it appears very clear that the extra-peri- 
toneal mode of herniotomy is quite unsuitable when the stricture is 
formed by the sac or within it, whatever be the nature of the stricture 
itself; and the above-mentioned examples of strictures formed by mem- 
branous bands, suggest very strongly the propriety of great caution in 
arriving at the determination of adopting the extra-peritoneal division ; 
as well as, in those cases in which the sac is opened, of examining very 
carefully before the hernia be returned, whether membranous bands do 
or do not exist. 

The second indication which it is desirable to fulfil by an opera- 
tion, is the return of the hernia. 

With a view to facilitate the inquiry, as to which of the two modes of 
procedure is the more suitable, cases may be arranged into the three 
following classes : — 

First, Those in which the stricture is external to the sac, in which it 
is neither impracticable nor improper to return the hernia, and in which 
no obstacle exists to that return after the stricture has been divided. 
Secondly, Those in which an obstacle does exist after division of the 
stricture : and, Thirdly, Those in which the return of the included intes- 
tine would be practicable, but improper. 

First, In cases belonging to the first class, either mode is applicable ; 
but extra-peritoneal division being attended with much less danger, is 
decidedly preferable. 

Secondly, [In regard to cases in which, independent of the stricture, 
an obstacle to reduction exists, it will be proper to consider what are 
the principal obstacles most frequently met with. These are adhesions 
of the protruded parts to the hernial sac, the natural means of connex- 
ion, in some rare cases ; adhesions of the protruded parts to each 
other ; and the large size of the hernia. 

For a description of these obstacles to reduction, the reader is referred 
to the section on irreducible hernia. 

If any of these conditions exist, and if the sac be not opened, reduc- 
tion is in general impracticable. If the sac be opened, two of them 
may easily be overcome ; namely, the soft recent adhesions, formed by 
coagulable lymph and the filamentous, — the former can be broken down 
with the finger, the latter divided by the knife. Two of them present 
an insuperable impediment to reduction ; namely, the natural means of 
connexion, and the close organized adhesions, if these be to a great 
extent, and the hernia large. With regard to the two remaining condi- 
tions, the possibility of overcoming them, and the propriety of attempt- 
ing to do so, must depend entirely on the particular circumstances of 
the case ; but frequently, it is more judicious not to interfere with them, 
unless they exist only to a limited extent, and in hernise of moderate 
size. Most of these conditions, however, are principally met in cases of 
large and old hernia; and, on account of the risk of injuring the intes- 
tine in attempts at reduction, as well as that of inducing dangerous 
inflammation by much handling of the intestine, and the difficulty of 



474 HERNIA. 

maintaining the parts reduced, even should reduction be possible, the 
majority of surgeons seem now disposed to follow the advice of Sir 
Astley Cooper regarding such cases. His practice was, to divide the 
stricture, which fortunately in such cases is, for the most part, external 
to the sac, and to leave the latter unopened, and the hernia unreduced. 
The stricture being divided, the principal cause of danger is removed. 
The coverings of the hernia should be replaced, and proper means taken 
for promoting the healing of the wound. 

Thirdly, There are certain states in which it would be extremely im- 
proper to attempt reduction ; namely, when the hernia is gangrenous, 
or when the intestine has given way from inflammation having gone on 
to gangrene, or when it has been torn, or accidentally wounded in the 
operation. The two last-mentioned conditions can only result from 
unskilfulness in the mode of procedure ; but, should they exist, the 
hernia ought not to be returned. When the intestine presents such an 
appearance as to render it doubtful whether its return may be followed 
by faecal extravasation, the surgeon should content himself with care- 
fully dividing the stricture. In all cases in which the intestine is gan- 
grenous, or not entire from whatever cause, it ought to be allowed to 
remain, so that the faeces passing off by the wound may form an abnor- 
mal anus, and extravasation into the abdomen be thereby prevented. 
When omentum forms the hernia, and it is gangrenous, the gangrenous 
portion may be removed, and the remaining part returned to the 
abdominal aspect of the mouth of the hernial sac. The practice of re- 
moving a portion of omentum, when from growth it renders a hernia 
irreducible after division of the stricture, is a proceeding which, in some 
cases, may be adopted with advantage. For cases belonging to this 
class, extra-peritoneal division is of course quite unsuitable. These 
remarks, it is to be hoped, will be sufficient to point out the proper 
mode of procedure when the hernia is sound, and reducible after division 
of the stricture ; when it is irreducible after such division — and when it 
is in any of the various conditions in which reduction would be dangerous 
and improper ; and also to show, that to follow one method indiscrimi- 
nately in all cases would be unwise ; that intra or extra-peritoneal 
division should be adopted according to the particular circumstances of 
the case ; that in the majority of cases intra-peritoneal division is not 
only the more suitable mode, but the only one which is safe, or by which 
any good can be effected; and that the cases in which extra-peritoneal 
division is suitable are those of very short standing, where there is no 
reason to apprehend the existence of adhesions, or of an unsound condi- 
tion of the hernia; and those also of large and old hernia, where the 
more judicious proceeding is to divide the stricture, and not to attempt 
reduction. 

The plan of not opening the sac, although practised in certain cases 
by Franco and Pare", was first strongly recommended by Petit, and con- 
sequently has been designated the method of Petit, to distinguish it 
from the mode in common use. Petit practised this method as early as 
1718. It was subsequently advocated by Garengeot ; and, at a still 
later period, adopted and strongly recommended by Bonnet of Lyons. 

In this country it was introduced by the second Monro, who advocated 



HERNIA. 475 

its adoption in cases of small and recent hernia, and mentioned four 
cases in which he resorted to that mode of proceeding. In one of them, 
however, adhesions prevented the return of the hernia, and in two of 
them he was obliged to cut the neck of the sac. In later times, the 
same proceeding was adopted by Sir Astley Cooper in cases of large and 
old hernia, and strongly recommended by him as the decidedly prefera- 
ble mode in cases of that class. Mr. Lawrence, in his valuable " Treatise 
on Ruptures," remarks, a The plan of removing the stricture, and re- 
turning the prolapsed parts without opening the sac at all, ought, I 
think, to be more frequently adopted than it has hitherto been, although 
it appears objectionable as a measure of general use, in the operation 
for strangulated hernia." To Mr. Key, however, the merit undoubtedly 
belongs of having recommended a more general adoption of Petit's mode 
than had previously prevailed in this country. In his admirable " Me- 
moir on the Advantages and Practicability of dividing the Stricture in 
Strangulated Hernia on the outside of the Sac," published in 1833, will 
be found much valuable information on this interesting subject. Mr. 
Luke of the London Hospital strongly recommends this mode, and his 
success is a decided testimony in its favour. Out of nearly forty patients 
he has not lost more than two. In October, 1845, when I had occasion 
to be in London, Mr. Liston showed me a patient in the North London 
Hospital, in whose case he had adopted this mode ; and, in a communi- 
cation I afterwards received from him, he informed me that he had 
practised it in a few other instances, and felt convinced of its being the 
preferable mode when the hernia is small and recent, and when there is 
no reason to apprehend an unsound state of the intestine. And, judging 
from the recorded statements of some other distinguished surgeons, this 
mode seems to be meeting with deservedly increased favour ; and I have 
no doubt will continue to do so, if practised under the limitations already 
mentioned. 

There can be no doubt that intestinal inflammation is the most fre- 
quent cause of death after the operation for strangulated hernia. Some 
of the advocates of Petit's method have assigned as the causes of that 
inflammation, when the ordinary proceeding is adopted, the exposure of 
the intestine to light and air, change of temperature and handling. I 
agree with Mr. Lawrence in ascribing it not to these agents, but chiefly 
to the long-continued pressure of the stricture, owing to the operation 
being too long delayed, and to an injudicious and too frequent use of 
the taxis previous to the operation. I remember being very much 
struck with an observation of Desault's ; I have not his works beside 
me at present, but it is to this effect : — " Think well of that hernia 
which has been little handled and soon operated on." The operation 
is justifiable and necessary, when the patient has been brought fully 
under the influence of chloroform, and the taxis has been fairly, fully, 
and skilfully tried without producing the desired effect. The conviction 
being thus produced, that by no other means than an operation is there 
hope of saving the life of the patient, it ought to be resorted to as 
quickly as possible. Much handling must not only give unnecessary 
pain, but also increase the risk of hurrying on the inflammation to 
results which, even though the operation should be performed, would 



476 HERNIA. 

render it unsafe to return the hernia. When therefore the taxis has 
been fairly and skilfully tried, on a patient fully under the influence of 
chloroform, no advantage can, but considerable injury may, result from 
the repetition of treatment already found to be unavailing. Many con- 
siderations show that the operation should be performed as soon as possi- 
ble, after its inevitable necessity has been found to exist. Delay, like 
undue handling, increases the risk of inducing such a state of the hernia 
in consequence of inflammation, as would render its return unsafe. 
From the circumstance that a hernia may speedily prove fatal, and 
from the depressed state which comes on in consequence of delay, ren- 
dering the patient less able to stand the shock of an operation, will be 
seen the importance of being as prompt as possible ; but there is another, 
and a very urgent reason — namely, that, if the operation be delayed 
until intestinal inflammation has been induced within the abdomen, it is 
far from certain that this inflammation will subside on the removal of 
the hernia which caused it. I have performed the operation for stran- 
gulated hernia, according to the usual mode, a considerable number of 
times, I believe twenty-three in all, and except in one case, where death 
occurred in consequence of an attack of phlegmonous erysipelas which 
commenced after the patient was considered out of all danger) in every 
instance with success. This success I attribute to two things — namely, 
avoiding all undue and useless handling, and performing the operation 
early. My decided impression is, that the reason why the operation is 
so frequently followed by death, instead of being one of the most suc- 
cessful of the great operations of surgery, is too great delay in resorting 
to an operation, and the undue and the injurious use of the taxis, even 
after its adoption has proved unavailing. 

6th. Abnormal or artificial anus, its anatomy and treatment. When- 
ever the intestine is unsound, or not entire, it should be allowed to re- 
main, the safety of the patient in such cases consisting, in the formation 
of an abnormal anus. Lymph is thrown out along the abdominal aspect 
of the mouth of the sac, by which means the intestine becomes con- 
nected to the walls of the abdomen, and the danger of faecal extravasa- 
tion is diminished. The portion of intestine leading to the abnormal 
anus, that is, the upper or gastric portion, sends down its contents, and 
they are discharged by the wound ; their transmission into the lower 
or rectal portion, that is, the part leading from the abnormal anus, 
being prevented partly by the contraction of that portion from being 
empty, and its retraction ; but principally by the septum formed by the 
contiguous portions of the bowel. The completeness of this partition 
(called by some the spur, ldperon), and consequently of the hindrance 
of the passage of the faeces from the one end of the intestine to the 
other, varies according as the entire diameter of a loop of intestine, or 
a part of it only, is included in the stricture. If the whole diameter 
be included, the portions of intestine will be in a measure parallel, and 
the partition complete. The danger of abnormal anus varies according 
to the part of the bowel affected. If it be a portion of the great intes- 
tine, the only consequences may be discomfort and inconvenience ; 
whereas if it be a portion of the small intestine, and more especially 
if it be near the commencement of the jejunum, the chyle will run to 



HERNIA. 477 

waste, and death from inanition probably follow. The upper portion 
remains open, its mucous membrane in some instances projecting, and 
discharges its contents into a cavity conical in form, the base being 
round the breach of the intestine, and the apex at the aperture in the 
abdominal parietes. An excellent writer on surgery says, " In an ab- 
normal anus of long standing, another phenomenon is observed : the 
two ends of the intestine retract inwards. Scarpa explained this by a 
movement of traction exercised on them by the mesentery, which move- 
ment, we think, is owing solely to the peristaltic motions of the intes- 
tine. There is then formed a membranous canal from the intestine to 
the surface, called the funnel (l'entonnoir), which serves as a way of 
communication between the two ends of the intestine ; and when the 
spur is not very prominent, but strongly retracted, it ends by bringing 
about the complete return of the fsecal matters into the inferior end, 
and the spontaneous cure of the artificial anus." Nature thus in some 
cases effects a cure without any other assistance than attention to re- 
gimen and pressure on the external aperture, for the double purpose 
of preventing protrusion of the mucous membrane^ and of presenting 
an obstacle to the passage of the fasces outwards. Desault was the first 
who effected a radical cure of abnormal anus by surgical treatment ; but 
his method, though successful, is not very generally applicable. To 
Dupuytren the merit belongs of having devised, and successfully prac- 
tised, an ingenious and more generally applicable mode of effecting a 
radical cure. His object was the destruction of the septum, which offers 
the principal obstacle to the restoration of the normal canal ; and the 
plan which he ultimately adopted for that purpose was, to produce a 
slough of the septum by subjecting it to pressure between the blades 
of a screw-forceps ; the two blades having been introduced, one into 
each portion of the bowel, are made to approach each other by the 
turning of the screw, and the partition deprived of its vitality by pres- 
sure ultimately comes away with the instrument, and the principal ob- 
stacle is thus removed. Of this method of treatment I have had no 
experience, but in the hands of Dupuytren it was found to be success- 
ful. It should never be ventured upon at an early period, lest the 
surrounding adhesions, which are so essential, should be broken, and 
lest the irritation should be so great that the extensive sloughing action 
produced might endanger the life of the patient. And when it is 
adopted, the utmost caution should be exercised, its effects should be 
closely watched, and care taken, especially at first, not to employ com- 
pression to such an extent as to cause distressing symptoms. The 
blades should not be introduced very far, lest by too extensive destruc- 
tion an opening be made into the cavity of the abdomen, or lest a loop 
of intestine be included between the parts. The restoration of the canal 
is also promoted by the occasional introduction of tents or bougies into 
the inferior portion of the canal. Dupuytren's method of treatment is 
clearly most applicable to those cases, in which the two portions of bowel 
are parallel to each other. 

7th. Treatment after the operation for strangulated hernia. 

After reduction it is advisable in general to give an opiate, and suita- 
ble means should be employed for promoting the healing of the wound: 



478 HERNIA. 

strict attention to rest, the recumbent posture,. and the careful regula- 
tion of the diet, are indispensable. After some little time, it is advisa- 
ble to endeavour to procure evacuation of the bowels by means of mild 
enemata ; but on no account whatever, should purgative medicines be 
given by the mouth for some considerable time after the operation. If 
inflammatory symptoms should appear, they must be combated by local 
and, if necessary, general depletion, fomentations, attention to regimen, 
the exhibition of calomel and opium, and other appropriate remedies. 
Pressure over the- wound should be kept up by means of a compress 
and bandage ; and before the patient is allowed to get out of bed and 
resume the erect posture, by means of a truss to diminish the danger of 
reprotrusion. 

THE DIFFERENT KINDS OF HERNIA, WHEN SITUATION IS MADE THE 
BASIS OF ARRANGEMENT. 

When situation is made the basis of arrangement, it is usual to divide 
hernise in accessible situations into four principal classes — -namely, in- 
guinal, femoral, umbilical, and ventral. 

I. INGUINAL HERNIA. 

In the language of surgery, inguinal hernia is a generic term, 
comprehending five different species — namely, oblique, direct, congenital 
and encysted congenital inguinal hernia, and hernia infantilis. These 
species, though all connected with the inguinal canal, yet differ from 
each other in their anatomy, relations, seats of stricture, &c, and each, 
therefore, requires to be particularly described. 

[But before entering into a special description of each, it may be 
proper to glance at the anatomy of the parietes of the abdomen, and 
particularly of those parts concerned in inguinal hernia. 

In the study of inguinal hernia, it must constantly be borne in mind, 
that the protrusion occurs at a natural weakness in the abdomen, through 
which the testicle and spermatic cord descend, towards the completion 
of foetal life ; and it will be useful, therefore, to study the relations of the 
different lamina of the abdomen, to the cord and testicle ; we should not 
forget, also, in the examination of the parts of a healthy abdomen in 
which no hernia existed, that the structures would be very much modi- 
fied by the affection. 

We might then say ; first, that a knowledge of the different layers of 
the abdomen is most important, for the cord and testicle are covered by 
a re-presentation of the same ; and secondly, that if the coverings of the 
cord are understood, there can be no difficulty in understanding those 
of the protrusion of the most common form, oblique inguinal hernia. 
The parts can be studied most satisfactorily by making two incisions, 
each commencing in the linea alba, one inch below the umbilicus, one 
extending to the pubes, and the other directed towards the crest of the 
ilium. 

Superficial fascia. — When the skin is removed by the incisions directed, 
a large portion of the superficial fascia of the abdomen is brought into 
view. It is composed of cellular tissue and capable of being split into 
layers. Its thickness varies in different subjects, and in different parts 



HERNIA. 



479 



of the abdomen. In fat subjects, the external layer will be found to 
have much fat contained within its meshes, and in such, therefore, a 
much deeper incision will be required to divide it. It is continuous with 
the superficial fascia of the thorax, the thigh and the perineum, and the 
deeper layer of it will be found to be connected with Poupart's ligament, 
the crest of the ilium, and the linea alba. Through the layers of this 
fascia ramify blood-vessels which may be cut in the operation for the 
relief of strangulated hernia. The principal artery in the lower part of 
the abdomen, is the arteria ad cutem abdominis of Haller, called fre- 
quently the external epigastric artery. Branches also of the external 
pudic arteries, or the veins accompanying, might also be cut, but the 
hemorrhage would be so slight as not to require a ligature to arrest it. 

Imbedded in this fascia near the groin we find the lymphatic glands. 
They will be found most numerous immediately over Poupart's ligament, 
and in the upper part of the thigh over the saphenous opening of the 
fascia lata. 

" When the superficial fascia is removed, the aponeurosis of the external 
oblique muscle is in view, together with, in the male body, the spermatic 
cord (in the female body, the round ligament of the uterus), which 
emerges from an opening close to the outer side of the spine of the 
pubes. The lowest fibres of the aponeurosis, as they approach the pubes, 
become separated into two bundles, which leave an interval between 
them for the passage of the cord or ligament just named. One of the 
bands, the upper one and smaller of the two, is fixed to the symphysis 
of the pubes ; and the lower band, 
which forms the lower margin of the 
aponeurosis, being stretched between 
the anterior superior spine of the 
ilium and the pubes is named Pou- 
part's ligament, or the femoral arch. 
This latter tendinous band has con- 
siderable breadth. It is fixed at the 
inner end to the spine of the pubes, 
and, for some space outside that 
process of the bone, to the pectineal 
ridge. In consequence of the po- 
sition of the pectineal ridge at the 
back part of the bone, the ligament 
is tucked backwards, and its upper 
surface affords space for the attach- 
ment of the other broad muscles, at 
the same time that it supports the 
spermatic cord. Poupart's ligament 
does not lie in a straight line be- 
tween its two fixed points ; it curves 
downwards, and -with the curved 
border the fascia lata is connected. It is owing to the last-mentioned 

Fig. 150. The aponeurosis of the external oblique muscle and the fascia lata. — 1. The 
internal pillar of the abdominal ring. 2. The external pillar of same (Poupart's liga- 
ment). 3. Transverse fibres of the aponeurosis. 4. Pubic part of the fascia lata. 5. 
The spermatic cord. 6. The long saphenous vein. 7. Fascia lata. 



Fig. 150. 




480 HERNIA. 

fact that the so-named ligament, together with the rest of the aponeu- 
rosis of the external oblique, is influenced by the position of the thigh, 
being relaxed when the limb is bent, and the converse. Moreover, the 
change of the position of the limb exercises a corresponding influence 
on the state of the other structures connected with Poupart's ligament. 

" The interval left by the separation of the fibres of the aponeurosis 
above referred to, is named the external abdominal ring, and the two 
bands by which it is bounded, are known as its pillars or columns. 
The space is triangular in shape, its base being the crista of the pubes, 
while the apex is at the point of separation of the two columns. The 
size of the ring varies considerably in different bodies ; in one case its 
sides will be found closely applied to the spermatic cord, while, in 
another, on the contrary, the space is so considerable as to be an obvious 
source of weakness to the abdominal parietes. It is usually smaller in 
the female than in the male body. 

" Between the pillars of the abdominal ring is stretched a thin fascia, 
named, from that circumstance, ' intercolumnar ;' and a thin diapha- 
nous membrane prolonged from the edges of the opening affords a cover- 
ing (fascia spermatica) to the spermatic cord and the tunica vaginalis 
testis. The cord passes through the ring over its outer pillar. 

" Internal oblique muscle. — After removing the aponeurosis of the ex- 
ternal oblique, this muscle is laid bare. The lower fibres are thin, and 

Fig. 151. 




often of a pale colour. Immediately above Poupart's ligament the outer 
part is muscular, the inner part tendinous. The spermatic cord, when 

Fig. 151. The aponeurosis of the external oblique muscle having been divided and 
turned down, the internal oblique is brought into view, with the spermatic cord escaping 
beneath its lower edge. — 1. Aponeurosis of the external oblique. V. Lower part of 
same, turned down. 2. Internal oblique muscle. 3. Spermatic cord. 4. Saphenous 
vein. 



HERNIA. 



481 



about to escape at the external abdominal ring, passes beneath the 
fleshy part of the muscle. The fibres in this situation varying consi- 
derably in direction from those of the rest of the muscle, pass inwards 
from Poupart's ligament at first nearly parallel with that structure ; and, 
becoming tendinous, they join with the tendon of the transversalis. 

" Transversalis muscle. — This muscle does not, in general, extend down 
as far as the internal oblique, so that the latter being removed, an inter- 
val is observable between the edge of the transversalis and Poupart's 
ligament, in which the transversalis fascia comes into view ; and in which 

Fig. 152. 




the spermatic cord is seen after having penetrated that fascia. The 
lower edge of the muscle is commonly close above the opening for the 
cord in the subjacent membrane, while the tendon curves to its inner 
side. So that the margin of the muscle with its tendon has a semicir- 
cular direction with respect to the aperture.- 

" The tendinous fibres in which the fleshy part of the two preceding 
muscles end, are connected together so as to form one layer, which is 
named the 'conjoined tendon of the internal oblique and transverse 

Fig. 152. After the removal of the lower part of the external oblique (with the excep- 
tion of a small slip including Poupart's ligament), the lower portion of the internal 
oblique was raised, and thereby the transversalis muscle and fascia have been brought 
into view. The femoral artery and vein are seen to a small extent, the fascia lata 
haying been turned aside and the sheath of the blood-vessels laid open. — 1. External 
oblique muscle. 2. Internal oblique. 2 / . Part of same turned up. 8. Transversalis 
muscle. Upon the last-named muscle is seen a branch of the circumflex iliac artery, 
with its companion veins ; and some ascending tendinous fibres are seen over the con- 
joined tendon of the two last-named muscles. 4. Transversalis fascia. 5. Spermatic 
cord covered with the infundibuliform fascia from preceding. 6. Upper angle of the 
iliac part of fascia lata. 7. The sheath of the femoral vessels. 8. Femoral artery. 9. 
Femoral vein. 10. Saphenous vein. 11. A vein joining it. 

31 



482 HERNIA. 

muscle.' This tendon is fixed to the crest of the pubes in front of the 
rectus muscle, and likewise to the pectineal ridge. It is thus behind 
the external abdominal ring, and serves to strengthen the wall of the 
abdomen where it is weakened by the presence of that opening. 

" A band of tendinous fibres (Fig. 152), directed upwards and inwards 
over the conjoined tendon in a triangular form, gives additional strength 
to the abdominal wall in the same situation, but the fibres of this struc- 
ture are often very indistinct. 

"Where the spermatic cord is in apposition with the preceding muscle, 
the cremaster muscle of the testis descends over it. The fibres which 
compose this muscle are, from their colour, more easily distinguished 
than the other investments of the cord ; and this is especially the case 
in robust persons, or when they are hypertrophied, as sometimes hap- 
pens in cases of long-standing hernia. The outer part of the cremaster 
is much larger than the portion connected with the pubes ; indeed, it 
sometimes happens that the latter is not to be discerned even with most 
careful dissection. 

" When observed in different bodies the lower part of the internal 
oblique and transverse muscles will be found to present some differences 
in their physical characters as well as in the manner in which they are 
disposed with respect to the spermatic cord. Thus: — 

" a. The transversalis, in some cases, is attached to but a small part of 
Poupart's ligament, and leaves, therefore, a larger part of the abdomi- 
nal wall without its support. On the other hand, that muscle may be 
found to extend so low down as to cover the internal abdominal ring 
together with the spermatic cord, for a short space. Not unfrequently 
the fleshy fibres of the two muscles are blended together as well as their 
tendons. 

"6. Cases occasionally occur in which the spermatic cord, instead of 
escaping beneath the margin of the internal oblique, is found to pass 
through the muscle, so that some muscular fibres are below as well as 
above it. And examples of the transversalis being penetrated by that 
structure in the same manner are recorded. 1 

" c. In his latest account of the structure of these parts Sir A. Cooper 
described the lower edge of the transversalis as curved all round the 
internal ring and the spermatic cord. 'But the lower edge of the 
transversalis has a very peculiar insertion, which I have hinted at in my 
work on hernia. It begins to be fixed in Poupart's ligament, almost 
immediately below the commencement of the internal ring, and it con- 
tinues to be inserted behind the spermatic cord into Poupart's ligament 
as far as the attachment of the rectus.' 2 With this disposition of its 
fibres, the muscle would, in the opinion of the last-cited authority, have 
the effect of a sphincter, in closing the internal ring, and would thus 
tend to prevent the occurrence of hernia. But the principal object with 
which the attention of surgeons has been fixed on the muscles in this 
situation, is in order to account for the active strangulation of hernial 
protrusion at the internal abdominal ring, and in the inguinal canal. 

1 Recherches Anatomiques sur les Hernies, &c., par J. Cloquet, pp. 18 and 23, Paris, 
1817. Inguinal and Femoral Hernise, by G. J. Guthrie, plate I., London, 1833. 

2 Observations on the Structure and Diseases of the Testis, second edition, p. 36. 
Ed. by Bransby B. Cooper, F.R.S. London, 1841. 



HERNIA. 483 

" Fascia transversalis. — Closely connected with the transversalis 
muscle by means of the cellular membrane interposed between the 
fleshy fibres of the muscle, it is united below to the posterior edge 
of Poupart's ligament, there joining with the fascia iliaca; and on 
the inner side it blends with the conjoined tendon of the internal 
oblique and transversalis muscles, as well as with the tendon of the 
rectus. The fascia possesses very different degrees of density in diffe- 
rent cases ; in some being little more than a loose cellular texture, while 
in others it is so resistant at the groin, — towards which part it increases 
in thickness, and especially at the inner side of the internal abdominal 
ring — that it is calculated to afford material assistance to the muscles in 
supporting the viscera. By an oval opening in this membrane the sper- 
matic cord (or the round ligament of the womb) begins its course through 
the abdominal parietes. This opening, named the internal abdominal 
ring, is opposite the middle of Poupart's ligament and usually close 
above that structure, but occasionally at a distance of three or four lines 
from it. Its size varies a good deal in different persons, and is consi- 
derably greater in the male than the female. From the edge of the 
ring a thin funnel-shaped elongation (infundibuliform fascia ; fascia 
spermatica interna, Cooper), is continued over the vessels of the sper- 
matic cord. 

" Epigastric artery. — The position of this vessel is one of the most im- 
portant points in the anatomy of the inguinal region, from the close 
connexion which it has with the different forms of inguinal hernia and 
with the femoral hernia. Accompanied by two veins (in some instances 
by only one) the vessel ascends under cover of the fascia last described 
obliquely to the rectus muscle, behind which it then proceeds to its ulti- 
mate distribution. In this course the artery runs along the inner side 
of the internal abdominal ring — close to the edge of the aperture, 
or at a short interval from it. The vessels of the spermatic cord 
are therefore near to the epigastric artery ; and the vas deferens, in 
turning from the ring into the pelvis, may be said to hook round it. 

" The Inguinal Canal. — This, the channel by which the spermatic cord 
passes through the abdominal muscles to the testis, begins at the inter- 
nal abdominal ring, and ends at the external one. It is oblique in its 
direction, being parallel with and immediately above the inner half of 
Poupart's ligament; and it measures two inches in length. In front, 
the canal is bounded by the aponeurosis of the external oblique muscle 
in its whole length, and at the outer end by the fleshy part of the inter- 
nal oblique also ; behind it, is the fascia transversalis, together with, 
towards the inner end, the conjoined tendon of the two deeper abdomi- 
nal muscles. Below, the canal is supported by the broad surface of 
Poupart's ligament, which separates it from the sheath of the large 
blood-vessels descending to the thigh, and from the femoral canal at the 
inner side of those vessels. 

"The spermatic cord, which occupies the inguinal canal, is composed 
of the arteries, veins, lymphatics, nerves, and excretory duct (vas defe- 
rens) of the testis, together with a quantity of loose cellular membrane 
mixed up with those parts. The direction of the vessels just enume- 



484 HERNIA. 

rated requires notice. The artery and vein incline outwards from the 
lumbar part of the vertebral column to reach the internal abdomi- 
nal ring, where, after being joined by the vas deferens as it emerges 
from the pelvis, they change their course, inclining inwards along the 
inguinal canal ; at the end of which they become vertical. There are 
thus repeated alterations in the direction of the vessels ; and while at 
the beginning and ending all are close to the middle line of the body, 
they are considerably removed from that point where they come toge- 
ther to emerge from the abdominal cavity. 

" The coverings given from the constituent parts of the abdominal wall 
to the spermatic cord and the testis, namely, the cremasteric muscular 
fibres with the two layers of fascia, between which those fibres are placed 
(the infundibuliform and spermatic fasciae), are very thin in their natu- 
ral state ; but they may be readily distinguished in a surgical operation 
from the investing superficial fascia, by their comparative density and 
the absence of fat. 

" In order to examine the peritonaeum at the groin it will be best to 
divide that membrane with the abdominal muscles by two incisions drawn 
from the umbilicus — one to the ilium, the other to the pubes. The flap thus 
formed being held somewhat outwards, and kept tense, a favourable view 
will be obtained of the two fosse (inguinal fossce or pouches) with the 
intervening crescentic fold. This fold is formed by the cord remaining 
from the obliterated umbilical artery, which being shorter than the 
outer surface of the serous sac, projects it inwards ; and as the length 
of the cord differs in different cases, so likewise does the size and promi- 
nence of the peritoneal fold vary accordingly. 

" The lowest part of the outer fossa will be generally found opposite to 
the entrance into the internal abdominal ring and the femoral ring, 
while the inner one corresponds with the situation of the external abdo- 
minal ring. But the cord representing the umbilical artery, which, it 
has been stated, causes the projection of the serous membrane into a 
fold, does not uniformly occupy the same position in all cases. Most 
frequently it is separated by an interval, from the epigastric artery, 
while in some cases it is immediately behind that vessel. There is ne- 
cessarily a corresponding variation in the extent of the external perito- 
neal fossa. 

" Between the peritoneum and the fascia lining the abdominal muscles 
is a connecting layer of cellular structure, named the subserous cellular 
membrane. A considerable quantity of fat is in some cases found in 
this membrane. 

" The relative position of some of the parts above referred to may be 
here conveniently stated, by means of measurements, made by Sir A. 
Cooper, and adopted after examination by J. Cloquet. But as the dis- 
tance between given parts varies in different cases, the following mea- 
surements must only be regarded as a general average :-— 



MALE. FEMA: 

" From the symphysis of the pubes to the anter. supr. spine of the ) r , inc j ies q ^ nc ^ 
ilium, . . . . . . 5 ' 

From the same point to the spine of the pubes, . 1| " If " 

to the inner part of the external abdominal 1 q, ti , it 



es. 



rinff, 



HERNIA. 



485 



From the same point to the inner edge of the internal abdominal Y q ; nc h es 34. inches 
ring, .... f 

11 " to the epigastric artery on the inner side of ) 03 a ^l " 

the internal abdominal ring, . J 4 

"From the preceding account of the structure of the abdominal wall at 
the groin, it will be inferred that the defence against the protrusion of 
the viscera from the cavity is here weaker than at other parts. The 
external oblique muscle and the fascia transversalis are perforated, while 
the two intervening muscles are thinner than elsewhere, and more or 
less defective. To this it must be added that the viscera are impelled 
towards the same part of the abdomen by the contraction of the dia- 
phragm and the other abdominal muscles, which occurs in the production 
of efforts to overcome resistance ; and these are the circumstances under 



which protrusions actually take place." 
p. 1286-1294.— Ed.] 



Quain and Sharpey's Anatomy, 



I. OBLIQUE INGUINAL 



This (called by some writers external inguinal hernia) is a hernia which 
leaves the abdomen at the internal aperture of the inguinal canal. The 
points which it is of importance clearly to understand regarding this 

Fig. 153. 




form of rupture will be seen by attending successively to its commence- 
ment — direction— coverings — relations to the inguinal canal, spermatic 
cord, and internal epigastric artery — its seats of stricture — and the 
operation, when symptoms of strangulation still continue after the em- 
ployment of all the measures proper for that state. 



Fig. 153. Drawing of the parts concerned in inguinal hernia, 
tion made by me for the surgical class. 



Taken from a dissec- 



486 



HERNIA, 



1. The commencement, as has been already stated, is at the internal 
aperture of the inguinal canal, where it begins by pushing the perito- 
neum before it. 

2. The direction varies in the different divisions of its course. While 
within the inguinal canal its direction is downwards, inwards, and for- 
wards, so that in using the taxis the pressure should be upwards, out- 
wards, and backwards. After leaving the inguinal canal, its direction 
is downwards, inwards, and a little backwards. If such a hernia do not 

leave the inguinal canal, it 
Fig- 154. Fig. 155. i s called a bubonocele ; but 

if it reach the scrotum in 
the male, it forms what is 
called scrotal hernia, or os- 
cheocele; or if the labium 
in the female, it constitutes 
a labial hernia : — these ap- 
11 ^^Bf^H^^ pellations being descriptive 

of the extent of the hernia. 
3. The coverings of an 
oblique inguinal hernia, if 
it extend beyond the ex- 
ternal aperture, are six in 
the male, and five in the 
female. In the male they 
are, from within outwards, 
the hernial sac, formed of 
peritoneum — the fascia in- 
fundibuliformis or internal 
spermatic fascia, derived 
from the margin of the in- 
ternal aperture — the cre- 
master muscle, called by 
some writers the fascia cre- 
masterica — the external 
spermatic fascia — the super- 
ficial fascia,, and the common integument. In the 
female the cremaster muscle is wanting. 

4. The relations of an oblique inguinal hernia 
to the inguinal canal, to the spermatic cord, and 
to the internal epigastric artery, are the follow- 
ing. It comes clown through the canal, differing 
greatly in this respect from direct inguinal 
hernia. ' The cord is behind, and the hernia 
in front, as might be expected, considering the different ways in which 
the hernia and the cord reach the internal aperture ; and the internal 
epigastric artery is to the pubic side of the neck of the hernia, but 

Fig. 154. Hernial sac, showing its usual situation in front of the spermatic cord. 
From a preparation in my own museum. 

Fig. 155. Hernial sac, accompanied by varicocele: showing the spermatic cord split, 
the vessels lying on one side, and the vas deferens on the other. Taken from a prepa- 
ration in my own museum. 




HERNIA. 



487 



Fig. 156. 



Fig. 157. 




behind the fascia transversalis, and separated bj it from the canal. 
If the hernia be of considerable standing, the different parts com- 
posing the cord may be separated from each other, some being bent 
to one side, and some to the other ; and occasionally some have been 
found nearly in front ; but these are deviations from the usual con- 
dition. The relation which is the most 
important of all to be kept in view is, 
that the internal epigastric artery is on 
the pubic side of the neck of the hernia. 

5. The seats of stricture in this species of 
hernia are three — first, at the external 
aperture ; this, however, is of very rare 
occurrence, except in cases of large and 
old hernia, when it is sometimes met with, 
and may then be formed either by the 
circumference of the aperture, or by the 
hernial sac ; secondly, between the exter- 
nal and internal apertures, in which case 
it may be formed by the under borders of 
the internal oblique and transversalis 
muscles, or by the hernial sac, or by being 
embraced by the fibres of the above mus- 
cles, the cord and the hernia having in 
some cases fibres behind as well as in 
front ; and, thirdly, at the internal aper- 
ture, in which case it may be formed 
either by the fascia transversalis where 
it forms the aperture, or by the hernial 
sac. The correctness of these statements 
as to the seats of stricture and the parts 
by which they may be formed, I have 
had opportunities of testing in my own 
dissections and operations. 

6. The operation. As all the details 
of the operation for strangulated hernia 
in general are applicable to the operation 
for this particular species, I shall here 
only point out the modifications rendered 
necessary by the anatomical relations. 
The incision of the integument should 
commence about half an inch above the 
internal aperture, follow the direction of 
the long diameter of the tumour, and de- 
scend to near its base. One simple inci- 
sion suffices. The next step is, to lay 
bare the hernial sac by the cautious division of the other coverings, and 
if intraperitoneal division be the prudent mode of procedure, to open the 
sac, attending carefully to the precautions already mentioned. The her- 
nial sac having been opened, and the seat of the stricture ascertained by 
passing the point of the fore-finger upwards within the sac and in front 
of the hernia, the hernial knife is sent up on the palmar aspect of the 



488 



HERNIA, 



finger as a director, care being taken to avoid wounding the hernia ; 
and for this purpose it should be sent up with the side resting on the 
finger until its pointed extremity be within the stricture, when the edge 
should be turned forwards to the stricture and the division made, during 
which process the action of the right hand which moves the knife is 
accommodated to that of the left index finger which to a certain extent 
guides the knife, and also prevents the hernia from coming against its 
edge. An important question is, in what direction the stricture should 
be divided. If the stricture be at the external aperture, or at the 
under border of the internal oblique and transversalis muscles, there is 
no artery to be afraid of, and the division can be safely effected by 
carrying the knife upwards and inwards, directly upwards, or upwards 
and outwards ; but if the stricture be at the internal aperture, there 
would be danger of wounding the internal epigastric artery if the inci- 
sion were carried upwards and inwards ; it can, therefore, be made with 
safety only in two directions, namely, upwards and outwards, or directly 
upwards. 

The same proceeding as regards the direction of the incision in di- 
viding the stricture is adopted in all cases of inguinal hernia. It was 
first recommended by J. L. Petit, and by Scarpa, and afterwards by 
Bicherand, Dupuytren, and other continental authorities ; and in this 
country it was very strongly advocated by Sir Astley Cooper, who 
recommended in all cases of dividing the stricture, to cut directly 
upwards — a practice which has deservedly received general adoption. 

II. DIRECT INGUINAL HERNIA. 

In explaining the anatomy of direct inguinal hernia, we shall follow 
the same order as in the former case. 

Fig. 158. 




1. The commencement of a direct inguinal hernia is opposite the exter- 
nal aperture, through which it comes usually by pushing the posterior 
wall of the inguinal canal before it, but in some instances by rupturing 
a part of it. 

Fig. 158. From Druitt. 



HERNIA. 



489 



2. Its direction before leaving the aperture is directly forwards ; after 
leaving it, it is the same as that of an oblique inguinal hernia in the 
corresponding part of its course. 

3. The coverings of a direct inguinal hernia, from within outwards, 
are the hernial sac — the fascia transversalis with the conjoined fibres of 
the internal oblique and transversalis muscles, provided they be not rup- 
tured — a very imperfect covering from the cremaster muscle — the exter- 
nal spermatic fascia — the superficial fascia, and the common integument. 
In the female, as there is no cremaster muscle, there is one covering 
less. These coverings differ from those of oblique inguinal hernia in two 
particulars — namely, that formed by the cremaster muscle is in this case 
less perfect ; and the second from within outwards, instead of being 
formed by the internal spermatic fascia given off from the internal 
aperture of the inguinal canal, is formed by the fascia transversalis 
itself assisted by the conjoined fibres of the 
internal oblique and transversalis muscles, 
except when they have been ruptured, or 
separated from each other. 

4. With regard to its relations to the 
inguinal canal, spermatic cord, and in- 
ternal epigastric artery, we may remark 
that it does not come down through the 
canal, but directly through its external 
aperture ; that the cord, instead of being 
behind it, is on its outer side ; and that the 
artery, instead of being on the pubic, is on 
the iliac side of the neck of the hernia. 
This last peculiarity is most important to be 
remembered, and it is thus seen that oblique 
and direct inguinal hernise have opposite 
relations to the internal epigastric artery. 

5. The seats of stricture in this species 
are only two : namely, at the external aper- 
ture — which, however, is a rare occurrence, 
and then the stricture may be formed either 
by the circumference of the aperture, or by 
the hernial sac ; and at the under border of 
the internal oblique and transversalis mus- 
cles, the stricture being formed by them, or 
by the hernial sac itself. 

6. After what has been stated regarding 
the operation for strangulated hernia in 
general, and that for oblique inguinal hernia, 
it seems unnecessary to do more than add, 
that when the stricture is at the under bor- 
der of the internal oblique and transversalis muscles 

Fig. 159. Drawing of the sac of a direct inguinal hernia ; showing the mouth of the 
sac lying on the pubic side of the deep epigastric vessels, and the spermatic cord split 
so thatits vessels lie behind, and the vas deferens in front of the sac. From a prepa- 
ration in my own museum. 




490 



HERNIA. 



dividing the stricture could be carried directly upwards, or up- 
wards and inwards, without going in the direction of the internal 
epigastric artery; but not upwards and outwards. It would be 
unsafe to cut upwards and outwards in direct inguinal hernia, or up- 
wards and inwards in oblique ; and as it is difficult or impossible in 
some cases to determine whether the hernia be oblique or direct, from 
the weight of the hernia having drawn down the internal aperture to be 
opposite the external, it is proper to adopt the rule already laid down 
— namely, in all cases of inguinal hernia, in dividing the stricture to 
cut directly upwards. It may be briefly stated, that the operation is 
performed by making an incision through the integuments in the direc- 
tion of the tumour, and extending from its upper to its under part, and 
cutting through the other coverings until the hernial sac is brought 
into view. The hernial sac is then opened, strict attention being paid 
to the precautions before mentioned. The forefinger of the left hand is 

Fig. 160. 




then introduced into the sac, and carried up to the stricture, and the 
palmar aspect of the finger used as a director for conducting the knife 
up to the stricture, and as a guard to prevent the knife from coming 
against the hernia. The extremity of the knife having been introduced 
below the stricture, its edge should be directed towards the stricture, 
and division effected by cutting directly upwards. The hernial contents 
should then be returned, if such a proceeding is possible and proper ; if 
not, the treatment formerly described should be adopted. 



CONGENITAL INGUINAL HERNIA. 



Congenital inguinal hernia — more properly called hernia into the 
tunica vaginalis, because while it is usually congenital, or met with in 
young infants, it sometimes, though rarely, presents itself at a more 
advanced age — differs from the two species already described, in that 

Fig. 160. From Listen. 



HERNIA. 



491 



they, if they descend into the scrotum, are without, as is shown in the ac- 
companying delineation, but this is contained within the tunica vaginalis. 
The two accompanying diagrams, though somewhat altered and improved, 
taken from the works of a writer who was once a great ornament of 

Fig. 161. 




the surgical profession, shows the opposite relations of common and 
congenital inguinal hernia to the tunica vaginalis. The manner in 
which this species of hernia is formed, may be thus explained. Although 
the tubular portion of peritoneum, which, for a short time after the 
descent of the testicle, forms a canal of communication between the 
tunica vaginalis within the scrotum and the peritoneum within the 
abdomen, usually becomes very soon occluded, and ultimately quite 

Fig. 162. 




obliterated, so that the cavity of the tunica vaginalis is perfectly 
separated from that of the abdomen, yet in some cases the tubular por- 

Fig. 161. A scrotal hernia; showing the usual relation of the sac to the tunica 
vaginalis. 

Fig. 162. Congenital scrotal hernia ; showing the situation of the hernia within the 
tunica vaginalis. 



492 HERNIA. 

tion does not exhibit its usual disposition to close and become obliterated, 
and while this state continues, on crying or making some exertion, a 
portion of intestine may be sent down through the tubular canal into 
the cavity of the tunica vaginalis, and thus constitute what is called a 
congenital hernia. As it is only after the inflation of the lungs that the 
usual exciting causes are applied, this variety rarely occurs till after 
birth ; but sometimes a portion of intestine in contact with the testicle 
while within the abdomen, adheres to the testicle, and descends with it 
into the scrotum afrthe usual time at which the gland leaves the abdomen, 
and in such cases constitutes the hernia prior to birth. Congenital 
hernia is almost invariably formed of intestine alone ; the omentum 
very rarely descending so far as the commencement of the tubular 
canal. The principal peculiarities distinguishing this from the two 
former species are, that it has no hernial sac of peritoneum proper to 
itself, the tunica vaginalis being its immediate investment and forming 
its hernial sac ; that it is in contact with the testicle, which consequently 
cannot be so distinctly felt as in the more common species ; that the 
whole swelling is more uniform and firm than in an oblique or direct 
inguinal hernia, and that the different parts are less easily felt and dis- 
tinguished. Most of these peculiarities depend on that previously 
mentioned, namely, its being within the tunica vaginalis, which is 
thicker and firmer than the peritoneum, which forms the sac in the more 
common varieties. The descent of this species is usually sudden and 
complete. 

For this variety in its different states of reducible, irreducible, and 
strangulated, the same rules are to be followed as have been already 
laid down for the treatment of hernia in general. When it is found in 
adults, and becomes strangulated and requires an operation, the seat of 
stricture is almost invariably higher up than the external aperture, and 
the operation is more difficult than in oblique or direct hernia, from the 
parts being concealed and the parietes being thickened. 'The incision 
should not be carried further down than to within about three inches of 
the under part of the tunica vaginalis, because as that membrane has 
to be opened, if the incision were carried lower, the testicle would be 
unnecessarily exposed to irritation. In other respects the operation is 
the same as for oblique inguinal hernia. 

IV. ENCYSTED CONGENITAL INGUINAL HERNIA. 

This variety, which is still more rare than the former, has been more 
properly termed encysted hernia of the tunica vaginalis ; for though, like 
the last species, it is within, yet it is not in contact with the tunica va- 
ginalis, but is separated from it by a hernial sac. That the hernia 
is within the tunica vaginalis, and that it is contained within a hernial 
sac, there is no doubt. There has indeed been some difference of opi- 
nion as to the mode of formation of the sac, but it now seems nearly cer- 
tain from various dissections that it is formed in one or other of the 
two following ways. If the tunica vaginalis remain open in every way 
except at the abdominal canal, and if imperfect adhesions form at that 
point, and a hernia descend into the part above the adhesions, the ad- 
hesions becoming elongated and pushed down before the hernia constitute 



HERNIA. 



493 



the hernial sac — the sac proceeding from, and adhering firmly to the 
tubular portion of membrane between the abdomen and the tunica va- 
ginalis. Or, if the tunica vaginalis remain open everywhere except at 
one part, and be there imperfectly closed, the peritoneum being pressed 
down before the hernia into the tunica vaginalis will thus constitute a 



serous covering for the hernia. 



ERNIA INFANTILIS. 



This term is applied to a very rare species of hernia, originating in 
early life, which may be said to consist of a hernia with the usual peri- 
toneal sac placed behind the tunica vaginalis. The way in which it 
takes place may be thus explained. The cavity of the tunica vaginalis 
is unusually large, contains some serous fluid, and ascends high up in 
the cord, although its communication with the abdomen is occluded. 
The hernia, with the usual peritoneal sac, is sent down behind the tunica 
vaginalis, and in consequence, three layers of serous membrane, namely, 
the front and back of the tunica vaginalis, and the front of the hernial 
sac, must be cut through before arriving at the substance of the hernia. 

II. FEMORAL HERNIA. 

A hernia is called femoral or crural when the descent takes place 
behind Poupart's ligament, through what is termed the femoral or cru- 
ral ring ; which ring being much larger in the female than in the male, 
from the space being greater between the anterior superior process of the 
ilium and the pubes, femoral hernia, which is in the male a very rare 
occurrence, is comparatively frequent in the female. The nomenclature 
adopted in the following description, is that employed by some of our 
best writers on anatomy, who call the space in which a femoral hernia 
is situated, the femoral or crural canal, its upper extremity the femoral 
ring or abdominal extremity, and the other the saphenous opening or 
femoral extremity of the femoral canal. 

["The muscles of the abdomen, beneath the edge of which the femoral 
hernia escapes, are represented by Fi 163 

the aponeurotic band of the external 
oblique muscle, which is commonly 
known as Poupart's ligament, but 
which, in connexion with the femoral 
hernia, is named the femoral or 
crural arch. Extending from the an- 
terior superior spine of the ilium to the 
pubes, this band widens at its inner 
end, and, inclining or folding back- 
wards, is fixed, to a part of the pecti- 
neal line, as well as to the spine of the 
pubic bone. The small triangular 
portion attached to the pectineal line 
is known as Gimbernat's ligament 
(Hey). The outer edge of this part 
is concave and sharp ; with other struc- 

Fig. 163. The innominate bone of the left side with, 1. The femoral or crural arch; 
2. Gimbernat's ligament. 




494 HERNIA. 

tures, to be presently described, it forms the inner boundary of the aper- 
ture through which the hernia descends. The breadth and strength of 
Gimbernat's ligament vary in different bodies, and with its breadth varies 
the size of the opening which receives the hernia. 

" The space comprised between the femoral arch and the excavated 
margin of the pelvis is occupied by the conjoined psoas and iliacus, with 
the anterior crural nerve between those muscles and the external iliac 
artery and vein at their inner side. Upon these structures the fascia 
which lines the abdomen is so arranged as to close the cavity against 
the escape of any part of the viscera, except at the inner side of the 
blood-vessels. But the arrangement of the parts situated thus deeply 
(towards the cavity of the abdomen) will be most conveniently entered 
upon after those nearer to the surface shall have been examined. To 
this examination we now proceed. 

" The general disposition of the superficial fascia met with on removing 
the common integument from the groin has been described. In con- 
nexion with the present subject, it will be enough to mention the fol- 
lowing facts. The deeper layer of this structure adheres closely to the 
edge of the saphenous opening, and the careful removal of it is neces- 
sary in order adequately to display that aperture. Where it masks the 
saphenous opening, the deep layer of the superficial fascia supports some 
lymphatic glands, the efferent vessels of which pass through it ; and the 
small portion of the membrane so perforated is named the cribriform 
fascia. The superficial and the deep fascia adhere together along the 
fold of the groin likewise, and this connexion between the two mem- 
branes serves the purpose, at least, of drawing the integument the more 
evenly into the fold of the groin, when the limb is bent at the hip-joint. 

"By Scarpa the deep layer of the superficial fascia which covers the 
abdomen was described as an emanation from the fascia lata, extended 
upwards over the external oblique muscle. 1 But different modes of 
viewing the continuity of such structures depend very much on the 
manner of conducting the dissection. In the present case, for example, 
the fascia may be said to proceed from above or from below, according 
as the parts are dissected from the abdomen downwards or from the 
thigh upwards. Such difference, however, is no more than a verbal one, 
the material fact being merely that the two membranes are connected 
together along the groin. 

" The separation of the fascia lata into two parts at the saphenous 
opening, and the positions and connexions of each part, having been de- 
scribed in detail, only a few points in the arrangement of this membrane 
will be noticed in this place. At the lower end of the saphenous open- 
ing the iliac division of the fascia is continuous with the pubic by a well- 
defined curved margin immediately above which the saphenous vein 
ends ; above the opening a pointed cornu (falciform process — Burns 2 ) of 

1 A Treatise on Hernia, translated by Wish art, p. 247. 

2 Edinb. Med. and Surg. Journal, -vol. ii. p. 2G3, and fig. 2. 

In the first edition of Hey's Practical Observations in Surgery, the upper end of this 
process of the fascia was named the "femoral ligament ;" and since then several anatomists 
have distinguished the same part as " Hey's ligament." But Mr. Hey dropped the desig- 
nation in the subsequent editions of the same work, and there seems no good reason for 
continuing it. Compare the original edition (1803), p. 151, and plate 4, with the third 
edition (1814), p. 147, and plates 4, 5, and 6. 



HERNIA. 



495 



the same portion of the fascia extending inwards in connexion with the 
femoral arch reaches Gimbernat's ligament ; and in the interval between 
the two points now referred to (i. e., from the upper to the lower end of 
the saphenous opening), the iliac layer of the fascia lata blends with the 
subjacent sheath of the femoral vessels as well as with the superficial 
fascia. The pubic part of the fascia covers the pectineus muscle, and 
is attached to the pectineal ridge of the pubes. Immediately below the 
femoral arch the iliac and pubic portions lie one before, the other be- 
hind the femoral blood-vessels and the sheath of these. They occupy 
the same position with respect to the femoral hernia. 

"The anterior or iliac part of the fascia lata being turned aside the 
sheath of the femoral vessels will be in view (Fig. 152). The sheath is 
divided by septa, so that each vessel is lodged in a separate compart- 
ment, and the vein is separated by a thin partition from the artery on 
one side and from the short canal for the lymphatics on the other side. 



Fig. 164. 



Fig. 165. 





Along the thigh the sheath is filled by the artery and vein, but behind 
the femoral arch it is widened at the inner side. Here it is perforated 



Fig. 164. The femoral vessels of the left side, with their sheath laid open, and a small 
hernia displayed. — 1. The lower part of the external oblique muscle. 2. The anterior 
superior spine of the ilium. 3. Iliacus muscle. 4. Sartorius. 5. Pubic part of the 
fascia lata. 6. Femoral artery. 7. Femoral vein. 8. A small hernia. 

Fig. 165. The groin of the right side dissected so as to display the deep femoral arch. 
— 1. The outer part of the femoral arch. 1 / . Part of the tendon of the external oblique 
muscle, including the femoral arch, and also the inner column of the external inguinal 
ring, projecting through which is seen a portion of the spermatic cord cut. 2. The 
femoral arch at its insertion into the spine of the pubes. The fibres outside the nu- 
meral are those of Gimbernat's ligament. 3. The outer part of the femoral sheath. 4. 
The spermatic cord,* after having perforated the fascia transversalis. 5. The deep 
femoral arch — its inner end where it is fixed to the pubes. 6. Internal oblique muscle. 
7. Transversalis. Beneath the lower edge of this muscle is seen the transversalis fas- 
cia, which continues into the femoral sheath under the deep femoral arch. 8. Con- 
joined tendons of the internal oblique and transversalis muscles. 9. A band of tendi- 
nous fibres directed upwards behind the external abdominal ring. 



496 HERNIA. 

for lymphatic vessels, and on this account is said to be ' cribriform.' 1 
This inner, wider part of the sheath it is that receives the femoral her- 
nia ; and in connexion with the anatomical description of that disease 
it is designated the femoral canal. At its upper end the sheath of the 
vessels is continuous with the lining membrane of the abdomen— with 
the fascia transversalis at its fore part, with the fascia iliaca behind. 

" When the femoral arch is being removed it will be found that a bun- 
dle of fibres, springing from its under surface outside the femoral vessels, 
extends across the fore part of the femoral sheath, and, widening at its 
inner end, is fixed to the pecten of the pubes behind Grimbernat's liga- 
ment. This tendinous band is known as the deep femoral arch. Con- 
nected with the same part of the pubes is the conjoined tendon of the 
internal oblique and transversalis muscles. The tendon lies behind the 
attachment of the deep femoral arch. In many cases the last-named 
structure is not strongly marked ; and it may be found to blend with 
the tendon of the muscles just referred to. Not unfrequently it is alto- 
gether wanting. 

"Attention being now directed to the internal surface of the abdo- 
men: — When the peritonaeum has been removed, it will be observed that 
the fasciae lining the cavity form, for the most part, a barrier against 
the occurrence of hernia ; for outside the iliac vessels the fascia iliaca 
and fascia transversalis are continuous one with the other behind the 
femoral arch. These fasciae are, in fact, but parts of the same mem- 
brane to which different names are assigned for the convenience of de- 
scription, just as distinctive names are applied to portions of the same 
artery. But where the iliac artery and vein occur the arrangement of 
the fasciae is different. The vessels rest upon the fascia iliaca ; and the 
membranes, instead of joining at an angle as elsewhere, are continued 
into their sheath in the manner above described. 2 

" The sheath is closely applied to the artery and vein, so that, in the 
natural or healthy state of the parts there is no space left for the for- 
mation of a hernia in the compartments which belong to those vessels ; 
but at the inner side of the blood-vessels will be found a depression 
which is occupied but partially with the lymphatics. This is the femo- 
ral ring, the orifice of the femoral canal. 

" Femoral ring. — After the removal of the peritonaeum, this opening 
is not at first distinctly discernible, being covered with the laminated 
cellular membrane (subserous) which intervenes between the peritonaeum 
and the walls of the abdomen. That part of the membrane which covers 
the ring was found by M. Cloquet to possess in some cases considerable 
density ; and, from being the only barrier in this situation between the 
abdomen and the top of the thigh, it was named by that observer the cru- 

1 The word "cribriform" being applied to this part as well as to the layer of the 
superficial fascia stretched across the saphenous opening, the two structures are dis- 
tinguished in the following manner : — the former is known as the cribriform portion of 
the sheath of the vessels, while to the latter is assigned the name of cribriform fascia. 

2 Some anatomists describe the sheath of the vessels as continued down from the 
membranes in the abdomen, while others regard it as an emanation from the fascia of 
the thigh, but continuous with the abdominal fasciae. As this difference in the manner 
of viewing the structure in question does not alter the facts in any way, it is quite 
immaterial which of the modes of description is adopted. But it appears to me most 
natural to regard the sheath as a production of the fascia lata. 



HERNIA. 497 

ral septum (septum crurale). But this structure is usually no more 
than loose cellular membrane, and it forms but a very slight partition. 
On clearing it away the ring is displayed. It is a narrow opening, 
usually of sufficient size to admit the end of the fore-finger; the size, 
however, varies in different cases, and it may be said to increase 
as the breadth of Gimbernat's ligament diminishes, and the converse. 
It is larger in the female than in the male body. On three sides the 
ring is bounded by very unyielding structures. In front are the femo- 
ral arches ; behind is the horizontal branch of the pubes covered by the 
pectineus muscle and the pubic layer of the fascia lata ; on the outer 
side lies the external iliac vein, but covered with its sheath ; and on 
the inner side are several layers of fibrous structure connected with the 
pectineal line of the pubes — namely, Gimbernat's ligament, the deep 
femoral arch, and the conjoined tendon of the two deeper abdominal 
muscles with the fascia transversalis. The last-mentioned structures — 
those bounding the ring at the inner side — present respectively a more 
or less sharp margin towards the opening. 

"Femoral canal. — From the femoral ring, which is its orifice, the 
canal continues downwards behind the iliac part of the fascia lata (its 
falciform process), in front of the pubic portion of the same membrane, 
and ends at the saphenous opening. It is about half an inch in length ; 
but in its length the canal varies a little in different cases. 

" Blood-vessels. — Besides the femoral vein, the position of which has 
been already stated, the epigastric artery is closely connected with the 
ring, lying above its outer side. It not unfrequently happens that the 
obturator artery descends into the pelvis at the outer side of the same 
opening, or immediately behind it ; and in some rare cases that vessel 
turns round the ring to its inner side. Moreover, an obturator vein 
occasionally has the same course ; and small branches of the epigastric 
artery will be generally found ramifying on the posterior aspect of Gim- 
bernat's ligament. In the male body, the spermatic vessels are sepa- 
rated from the canal only by the femoral arch. 

"To the foregoing account of the anatomical arrangement of the 
parts concerned in femoral hernia, may be added certain measurements, 
showing the distance of some of the most important from a given point. 
They are copied from the work of Sir A. Cooper : — * 

From the Symphysis pubis to the anterior spine of the ilium, . 
From same point to the middle of the iliac vein, 

" " to the origin of the epigastric artery, 

" " to the middle of the lunated edge of the 

fascia lata, .... 

" " to the middle of the femoral ring, 

The preceding description of the parts is copied from Quain and Shar- 
pey's Anatomy. — Ed.] 

Direction. — A femoral hernia may be said to have three peculiarities 
of direction, namely, at first, and while within the femoral canal, down- 
wards ; on arriving at the saphenous aperture, forwards ; and afterwards 
obliquely upwards and inwards ; thus describing an arch, the convexity 

1 On Crural Hernia, p. 5. 
32 



MALE. 

5| inches. 
2§ " 
3 


FEMALE. 

6 inches 
2| " 

H « 


H « 


2| " 


2i « 


9a a 



498 



HERNIA. 



of which is downwards, and in a measure embracing three of the four 
aspects of Poupart's ligament — namely, the posterior, femoral, and an- 
terior ; the neck of the hernia being behind the ligament, the body on 
its femoral aspect, although removed a very little from it, and its fundus 
in front. These peculiarities suggest the necessity of straightening the 

Fig. 166. 




hernia, or of bringing down its fundus, before efforts are made to return 
it by the taxis. The first change of direction is caused by the narrow- 
ing of the sheath, and its close adhesion to the vessels, together with 
the close adhesion of the iliac portion of the fascia lata to the front, and 
of the pubic portion of the same membrane to the back of the sheath at 
the under extremity of the femoral canal — conditions which, by produc- 
ing constriction, offer an obstacle to further descent in a perpendicular 
direction ; whereas there is little to impede the passage forward through 
the saphenous aperture. The second change of direction is caused partly 
by the firm adhesion of the fascia superficialis to the front of the fascia 
lata, but chiefly by the pressure against the superficial epigastric vessels, 
by which the forward progress of the hernia is opposed, whereas they 
offer no obstacle to its passing upwards in front of Poupart's ligament. 
Coverings. — The fascial coverings from within outwards are, First, 
the hernial sac, formed of peritoneum. Second, the sub-peritoneal cel- 
lular tissue which lines the femoral ring, or abdominal extremity of the 
femoral canal. This substance, called by some authors the septum 
crurale, is pressed down before the hernial sac, and, together with the 

Fig. 166. Drawing showing certain parts concerned in femoral and inguinal hernia. 



HERNIA. 499 

aggregate of textures, which in the normal condition occupy the femoral 
canal, constitutes the second covering. This covering is by some named 
the fascia propria, — a term applied by others to the third covering, con- 
sisting of the fascia infundibuliformis, or sheath of the femoral vessels, 
within which the hernia descends. The two last-mentioned coverings 
are, in many instances, so matted together as to form but one. Fourth, 
the layer of cellular tissue which spreads over the saphenous opening, 
and which is perforated by various vessels. This is by some called the 
cribriform fascia, and considered (I think, properly) as the deep layer 
of the superficial fascia; whereas it is described by others as the middle 
division of the fascia lata. Fifth, the superficial fascia with some ab- 
sorbent glands and adipose tissue ; and, Sixth, the common integument. 
There are great varieties with regard to the thickness of the coverings, 
and it is supposed that in some instances the hernia escapes through 
some of the openings in the femoral sheath and in the cribriform fascia, 
in which cases there will seem to be only two coverings interposed 
between the common integument and the hernial sac. I have been 
much struck, in my own operations, with the great difference in different 
cases of the thickness of the fascial coverings, and with the fact, that 
instead of six different membranes, constituting so many distinct cover- 
ings, as is the case in inguinal hernia, and as we might expect from con- 
templating the anatomy of the parts in the normal state, there are some- 
times found only three ; namely, the hernial sac ; a cellulo-adipose layer, 
which varies much in thickness in different cases ; and the skin. The 
greatest number, however, of fascial coverings which can present them- 
selves, are the six enumerated above. 

Anatomical relations of the Neck of the Hernial Sac. — The neck of a 
femoral hernia is related to the boundaries of the femoral ring as fol- 
lows, namely, posteriorly, to the fascia iliaca, where it covers the linea 
ilia pectinea ; anteriorly, to Poupart's ligament, lined by the prolonga- 
tion downwards of the fascia transversalis ; internally, to the base of 
Gimbernat's ligament, at the junction of the fascia iliaca and fascia 
transversalis ; and externally to the femoral vein, from which it is sepa- 
rated only by the interposition of a membranous slip. There is also 
another relation which sometimes exists, namely, to the obturator artery, 
when that vessel, instead of coming off from the internal iliac, arises 
from the external iliac by a common trunk with the internal epigastric. 
When it has that irregular origin, the obturator artery crosses the 
femoral ring as it dips into the pelvis on its way to the obturator fora- 
men, occasionally passing near to the posterior and iliac sides of the 
femoral ring, but much more frequently in front and towards the pubic 
side. In the latter case, if a hernia be present, the artery will embrace 
about two-thirds of the circumference of the abdominal aspect of the neck 
of the hernial sac, namely, the front and inner aspect ; so that when 
the stricture is found at the femoral ring, great caution should be used 
not to make too* extensive a division, or to send up the cutting edge of 
the instrument farther than is indispensable for dividing the tissue which 
constitutes the stricture. 

Seats of Stricture. — This is a subject on which much attention has 
been bestowed ; and although in some points a difference of opinion 



500 HERNIA.' 

exists, it is certain, from the testimonies of high surgical authorities, 
that the stricture may be at the femoral ring, the textures constituting 
the ring forming the stricture ; or at the saphenous extremity of the 
canal, and formed by the crescentic border of the fascia lata ; or at the 
neck of the sac, and formed either by the sac itself, or by thickened 
textures around. In my own operations, I have invariably found the 
stricture at the femoral ring, and the majority of authors agree, that 
it is found there more frequently than elsewhere ; but it is certain that 
it is sometimes found in the other situations mentioned. In some 
instances, a stricture has been found at more than one of the above 
sites at the same time. Such are the usual seats of stricture, and the 
constituting textures in this species of hernia; but in some rare in- 
stances strangulation has been found to be occasioned by a loop of in- 
testine, by a band of omentum, or (which is an extremely rare occur- 
rence) by the circumference of an unusual opening in Gimbernat's 
ligament. 

Operation. — The body having been properly placed, the first step of 
the operation consists in making the integumental incision, various 
forms of which have been adopted, some making a simple incision 
which is not the most convenient ; some a crucial, which is objected to, 
as the under part of the vertical portion might interfere with the vena 
saphena major ; some an incision, composed of two parts, the one 
oblique and in the course of Poupart's ligament, the other extending 
down from the former in a vertical direction, so that the incision is 

formed thus T^ , on the right side, and thus ""j , on the left ; others 



making an incision thus , and others adopting the same form in- 



verted, thus 



The last-mentioned form is convenient, and may 



be made without risk of wounding important parts underneath, by 
transfixing the skin after pinching it up, the vertical portion extending 
from about an inch and a half above the crural arch, in a line with the 
centre of the tumour ; and being met below by the transverse portion, 
which should go from one side of the tumour to the other, parallel to 
Poupart's ligament, but a little below it. The next step is to cut 
through the various coverings, and lay open the hernial sac. This 
having been done, and the fore-finger of the left hand introduced within 
the sac, and carried up in front of the hernia, and the seat of the stric- 
ture ascertained, the hernial knife, with its blunt point, should be car- 
ried up flat upon the finger, until its point be within the stricture, when 
its edge should be directed against the stricture, and the necessary divi- 
sion effected, by cutting directly forwards. Great care should be taken 
not to lacerate the intestine by the introduction of the finger, or to 
allow it to come against the edge of the knife, or to admit the knife 
farther than is absolutely necessary for the division of the stricture, lest 
the unusual disposition above mentioned of the internal epigastric 
artery should exist, and the edge of the knife should reach the artery. 



HERNIA. 501 

The remaining parts of the proceeding should be regulated by the prin- 
ciples laid down in the description of the operation in general. 

By the above proceeding, the operation may be accomplished with as 
little difficulty and risk, as by any other ; but it may be proper to add, 
that, as regards the direction in which the stricture is divided, the modes 
adopted are very various. If the stricture be at the saphenous opening, 
there is no particular danger to guard against, and the surgeon may, in 
dividing the stricture, cut upwards and inwards, directly upwards, or 
upwards and outwards, and the operation is comparatively easy ; and 
when it is at the femoral ring, the knife may be safely carried to a small 
extent inwards, into Gimbernat's ligament, upwards and inwards, 
directly upwards into Poupart's ligament, or upwards and outwards ; 
but not directly outwards, on account of the femoral vein. The cutting 
inwards into Gimbernat's ligament has been recommended by Mauchart, 
Richter, Gimbernat, Boyer, Roux, Hey, Lawrence, and Ferguson, and 
others have objected to it, because it is more difficult, from the greater 
depth, to cut into Gimbernat's, than into Poupart's ligament ; because 
there is, from the same reason, greater danger of cutting or tearing the 
intestine when endeavouring to get at the seat of the stricture, and also 
because so little additional room would be gained by the division of 
Gimbernat's ligament. The cutting upwards and inwards, recommended 
by Heister, Le Dran, Sabatier, Lassus, Chopart, Desault, and others, 
has been objected to on the ground, that if the hernia be in the male 
(which, however, is a comparatively rare occurrence), the knife is carried 
in the direction of the spermatic cord : but this danger seems to have 
been greatly exaggerated ; for the knife ought never to be carried so 
high as to endanger the cord in the male, or the round ligament of the 
uterus in the female. The direction of the incision adopted by Pott, 
Sir Astley Cooper, and many others, was directly forwards, that by 
Mr. Liston forwards and a little inwards. Sharp cut upwards and out- 
wards ; and so did Dupuytren, but a very different proceeding ; he car- 
ried the knife from within outwards, and from below upwards ; and 
although in this method, the edge of the instrument is no doubt carried 
in the direction in which the epigastric artery is found, there is no 
danger of the artery being wounded, as the knife is not carried so high 
as to be in danger of reaching it. Scarpa had recourse to multiple in- 
cision in the under border of the crural arch. 

III. UMBILICAL HERNIA. 

The cases of umbilical hernia have been variously arranged by various 
writers. Scarpa divides them into two classes, namely — the congenital, 
appearing in the infant at birth, and the adventitious, occurring at any 
after period : but a more convenient arrangement is that of Mr. Law- 
rence, who gives three varieties, namely — the congenital, which appears 
at birth ; the hernia of children, which appears after the navel has been 
formed ; and the'umbilical hernia of adults. 

CONGENITAL UMBILICAL HERNIA. 

The congenital variety is occasioned by an original deficiency in 
the formation of the umbilicus ; it exists at the period of birth, and is 
therefore properly called congenital ; it forms a tumour, conical in 



502 HERNIA. 

form, the contents of which are for the most part intestine sent into the 
cord between its vessels, the umbilical vein being usually above and 
the arteries below, or on either side. The external covering of the 
tumour near the base is composed of integument, but at a farther dis- 
tance it is formed by an expansion of the substance of the cord, for 
the hernia is sent through the umbilicus into the cord. The cavity is 
lined by a small peritoneal covering. 

The treatment consists in returning the hernia, and preventing a 
recurrence of the protrusion ;— two points of the utmost importance to 
attain, as in the event of the hernia not being reduced, the separation 
which must ensue of the expanded portion of the cord which forms part 
of the coverings, would expose the patient's life to the greatest danger. 
The method usually adopted in this country to prevent reprotrusion, is 
compression by means of compresses and a bandage. Another plan, to 
which reference will be made in the next section, is to use the ligature 
with compression. 

THE UMBILICAL HERNIA OF CHILDREN. 

In this, which is a very common species of umbilical hernia, the object 
of treatment is, to return the protruded parts, and to keep them in that 
condition until the contraction and subsequent obliteration of the um- 
bilical ring prevents any future reprotrusion. The means adopted for 
this purpose is compression, or the ligature ; the former is attended with 
less pain and risk, and has always been preferred by the great majority 
of British practitioners. Various modes have been employed for pro- 
ducing the requisite compression. A very convenient method is by a 
piece of cork covered with soft leather, and kept in the umbilicus by 
strips of adhesive plaster, the whole being retained by means of soap 
plaster spread on the leather, and applied in a transverse direction. 
Another method is, to apply the half of an ivory ball to the umbilicus, 
retaining it by adhesive plaster, and a bandage, or some other appliance 
for the same purpose. 

The treatment by ligature was practised by Desault and Dupuytren, 
and their example has been followed by some others. An able and 
successful member of the surgical profession has given the following 
account of it : — " The infant being laid on its back, and its head bent 
on its chest, and its thighs flexed on its pelvis, the surgeon reduces the 
hernia, retains it with his left forefinger, and with his right hand raising 
the parietes of the hernial pouch, he slides them between his fingers to 
make sure that no part remains in the sac. Being assured of this, his 
assistant makes several turns round the sac, at its base, with a waxed 
thread, each turn being well tightened and secured by a double knot. 
The tumour thus tied is enveloped in a bed of lint, maintained by a 
compress and bandage. On from the eighth to the tenth day the liga- 
ture falls off with the parts it has strangled and killed. A small ulcer 
results, which is soon healed. It is well for the child to wear a bandage 
for two or three months, the better to prevent a relapse." This mode 
of cure, however, has not gained the favourable opinions of the surgical 
authorities in this country. 

Various cases are recorded by Desault, and some are mentioned by 
Soemmering and others, in which spontaneous cures occurred from the 



HERNIA. 503 

natural tendency of the umbilicus, in early life, to close; but such 
occurrences are so rare that the surgeon is not warranted in leading cases 
to the unassisted efforts of nature. 

UMBILICAL HERNIA IN ADULTS. 

This is rarely met with in males, but more frequently in females. 
Pregnancy is one of its most usual exciting causes ; hence its compara- 
tive frequency in females who have borne many children. In almost 
all cases of umbilical hernia in adults, omentum forms some part of 
the hernia, and to this has been attributed the fact that in the greater 
number of instances in which strangulation occurs, the symptoms are 
less urgent than in most other species of hernia. An umbilical hernia 
may be reducible, irreducible, or strangulated ; and in each of these 
conditions the treatment should be conducted according to the principles 
laid down in the general doctrines of hernia. The coverings are very 
thin, consisting merely of the cicatrix of the navel, the hernial sac formed 
of peritoneum, and the very thin layer of cellular tissue by which they are 
connected together. In performing the operation, it should be remem- 
bered that these coverings are often exceedingly thin, and that although 
every umbilical hernia has originally a peritoneal sac, yet when the 
hernia is large, the sac becomes so thin by dilatation, or absorption, or 
both, as scarcely to be perceptible. When the peritoneum becomes 
exceedingly thin and adherent to the skin, the covering is often found 
to present the appearance of being formed of only one layer. The 
coverings may be divided by a longitudinal or any convenient form of 
incision, and the stricture may be divided by cutting upwards and to the 
left side. 

IV. VENTRAL HERNIA. 

By a ventral hernia is understood one through any part of the front 
of the abdomen, except the inguinal canal, the femoral canal, or the 
umbilicus. Cases belonging to this class should be treated according 
to the general principles already laid down. 



Such are the various classes into which hernise in accessible situations 
are divided. Occasionally, however, they are found in inaccessible situ- 
ations, — for example, in the diaphragm, the obturator foramen, or the 
greater ischiatic notch; constituting diaphragmatic obturator, or ischi- 
atic hernia. Sometimes cases occur of a mixed class ; for example, a 
perineal hernia, which consists of a descent between the bladder and 
the rectum, the swelling presenting itself in the perineum ; or a vaginal 
hernia, in which the tumour projects into the vagina. Examples of 
hernia in inaccessible situations are, happily, of rare occurrence ; they 
cannot be made the subject of surgical treatment ; and their existence 
only becomes a matter of certainty after death. 

I shall conclude this section on hernia with the following remarkable 
case of strangulation, caused by a diverticulum. I recorded the case in 
the number of the "Edinburgh Monthly Journal of Medical Science," 
for July, 1849 : 

David White, seventeen years of age, a fine-looking young man, had 
always enjoyed excellent health until the 22d of April ; on which day. 



504 HERNIA. 

while walking in the street, he was suddenly seized with sickness, 
vomiting, and violent pain in the abdomen ; the pain being constant, but 
attended with frequent paroxysms of aggravation. 

At the commencement of the attack the belly was not tumid, nor 
was there any tenderness on pressure — on the contrary, the patient 
had an inclination to compress the belly with his hands, especially 
during the paroxysms of pain, and to turn himself round in bed. In 
the course of five or six hours, however, the abdomen became tender to 
the touch, and ultimately so much so that the slightest touch occasioned 
pain and vomiting ; the belly gradually became tumid ; and the patient 
was obliged to preserve his body as motionless as possible in order to 
prevent the aggravation of pain. 

Such is the history of the symptoms, as given by my friend, Dr. 
George Morrison, who attended him from the commencement of the 
attack. 

My colleague, Professor M'Robin, and I saw the patient for the first 
time twenty-four hours previous to his death. His symptoms, when we 
saw him, were — distension of the abdomen ; constant violent pain, with 
paroxysms of aggravation like the tormina of ileus ; tenderness on pres- 
sure ; sickness, urgent vomiting of a greenish liquid ; no stool after the 
commencement of the attack ; pulse one hundred and thirty, small and 
feeble ; features collapsed, and the countenance expressive of great 
exhaustion. 

These symptoms continued for twenty-four hours, without undergoing 
any material change, death taking place within sixty hours from the 
commencement of the attack. 

The suddenness with which the symptoms appeared, their history, 
and the absence of swelling in any of the usual sites of hernia, produced 
a strong impression on the mind of Dr. Morrison, Professor M'Robin, and 
myself, that the symptoms were caused either by intussusception, or 
by internal hernia, or by some internal cause of strangulation ; in short, 
that it was a case of enteritis, occasioned by some internal mechanical 
cause. 

I made a post-mortem examination twenty-four hours after death, in 
presence of the medical gentlemen above mentioned. On opening the 
abdomen, a small quantity of sero-sanguineous fluid was found in the 
cavity of the peritoneum ; the stomach, and a great part of the small 
intestine, were greatly distended with flatus ; the distended portion of 
the intestine was much inflamed, and there were slight adhesions of 
lymph in some parts. The lower third of the ilium and the whole of 
the great intestine were collapsed, and of a perfectly healthy appear- 
ance. On displacing some of the convolutions of the small intestine, a 
portion of the ilium, twelve inches in length, was found greatly dis- 
tended, strangulated, and in a state approaching to gangrene ; the part 
of the intestine to the gastric extremity of the strangulated portion 
being violently distended and inflamed, and that to the rectal extremity 
being comparatively collapsed, and of a perfectly healthy appearance ; 
the strangulation being effected by a diverticulum of the ilium, having 
very peculiar relations and connexions. 

Fig. 167 of the accompanying drawings gives a front view of the 



HERNIA. 



505 



strangulated intestine and stricture. Fig. 168 gives a posterior view. 
Fig. 169 presents an appearance of the natural relations of the diverti- 
culum^ obtained after emptying the intestine, and withdrawing it from 
underneath the diverticulum by which it was strangulated. 

The diverticulum was an inch and a-half in length, and terminated in 
a slightly-dilated cul-de-sac ; from the extremity of which a membranous 
band was sent off, one extremity of which was evidently continuous with 
the serous coat of the diverticulum, and the other as evidently not 
merely attached to, but becoming continuous with, the anterior lamella 
of the mesentery. Through the aperture formed by the diverticulum, 
mesentery, and the portion of the intestine, from which the diverticulum 



Fig. 1G1 



Fig. 168. 





is continued, twelve inches of intestine had passed at the commencement 
of the attack, and became strangulated. 

The above cannot but be regarded as a very curious and extremely 
unusual case — not that it is rendered so by the mere existence of a di- 
verticulum, which is itself a rare formation, but the presence of a diver- 
ticulum being the occasion of strangulation. 

There is on record one case bearing a striking resemblance to the 
above. I allude to a preparation in the museum of St. Bartholomew's 
Hospital, of which I subjoin the description as extracted from the pub- 
lished catalogue of that valuable collection : — 

" Portion of small intestine, from which a diverticulum is continued. — 
The extremity of the diverticulum is adherent to the contiguous part of 

Fig. 167. Anterior view of the strangulated intestine and stricture; — a, gastric ex- 
tremity ; b, rectal extremity. 

Fig. 168. Posterior view of the strangulated intestine and stricture ; — a. gastric 
extremity ; b, rectal extremity. 



506 



HERNIA. 



the mesentery, so as to form a circular aperture or ring. Through this 
aperture a portion of intestine, twelve inches long, passed, and became 
strangulated. The patient, a lad subject to constipation, died four days 
after signs of strangulation of the intestine." 

Fig. 169. 




It will, however, be seen that, in one point at least, the cases differ : 
in that of St. Bartholomew's Museum, the fundus of the diverticulum is 
adherent to the contiguous portion of the mesentery — whereas, in the 
case I have described above the fundus of the diverticulum is con- 
nected with the mesentery by the serous coat becoming contracted 
into a membranous band, and expanding into the anterior lamella of 
the mesentery. In the catalogue of the museum of the Royal College 
of Surgeons in Ireland, there is a description of a preparation in 
which a diverticulum, four or five inches long, caused strangulation of 
several feet of intestine ; but the relations of the diverticulum, as well 
as the mode in which it effected strangulation, were very different from 
the case described above. 

Fig. 169. An appearance of the natural relations of the diverticulum to the intestine : 
a, gastric extremity ; b, rectal extremity. 



507 



CHAPTER XIV. 

WOUNDS OF THE ABDOMEN. 

Although the doctrines respecting the treatment of wounds generally 
is applicable to wounds of the abdomen, yet as these are particularly 
dangerous and require certain peculiarities of treatment, it is necessary 
to give a fuller account of the different sources of danger and of the 
treatment required in wounds of various kinds in that part of the body. 
There have been instances in which both the fixed and the floating vis- 
cera have been wounded, in which balls and shar'p instruments have 
passed through the body, and yet the patient has recovered ; but still 
when wounds of the abdomen are accompanied by injury of the contain- 
ed viscera, they are extremely dangerous, and in the majority of in- 
stances fatal. The chief sources of danger are hemorrhage, fatal depres- 
sion of the nervous system, extravasation of visceral contents, and peri- 
tonitis. 

Hemorrhage may prove fatal, either very speedily from the loss of 
blood, as when any large vessel in the abdomen is wounded, or when 
there is an extensive deep wound of such organs as the liver or spleen — 
such cases presenting the usual symptoms attendant on profuse internal 
hemorrhage ; or when the loss of blood is not of sufficient extent to pro- 
duce death, by its occasioning inflammation of the peritoneum, which 
quickly leads to the most unfavourable results. 

Depression of the nervous system, although generally attendant in a 
greater or less degree on wounds of the abdomen as well as on blows on 
that part, more rarely occurs to a fatal extent in the former than in the 
latter case ; yet sometimes it terminates in death, the sudden shock 
given to the nervous system causing the failure of the heart's action, — 
a result which has been supposed by some to occur more frequently 
after wounds of the stomach and duodenum than of the other viscera. 
' Extravasation of visceral contents does not occur so often as might be 
expected ; indeed, it is astonishing how seldom such effusion takes place 
in cases of a small wound of the intestine ; extravasation being in such 
cases prevented, in the first instance, by the constant equable pressure 
which the abdominal viscera exert on each other, the various surfaces 
being constantly in close contact, and by the tendency to protrusion of 
the mucous membrane, which plugs up the orifice, and afterwards by 
exudation of coagulable lymph on the exterior of the wound, by which 
and by adhesion to surrounding textures the breach becomes permanently 
repaired. By this process both hemorrhage and extravasation of intes- 
tinal contents are often prevented ; but if the viscus be full, or the 
wound very considerable, effusion of visceral contents into the sac of the 



508 WOUNDS OF THE ABDOMEN. 

peritoneum is very apt to take place ; and if so,- the result is certain to 
be fatal — for escape of bile, or of urine, from the great acrimony of these 
secretions, or of the contents of the alimentary canal, will produce the 
greatest possible suffering, which very speedily terminates in death. 
The most prominent symptoms in such cases are — sudden, unremitting, 
and excruciating pain, great prostration of strength, ghastly anxiety of 
countenance, extremely feeble pulse, and on the part of the patient, a 
decided conviction of approaching death. 

Peritonitis is another source of danger, and one so common that it may 
be said to be the cause of death in almost all fatal cases of penetrating 
wounds of the abdomen, excepting those in w T hich death takes place from 
the great and sudden loss of blood, or from the shock given to the ner- 
vous system, or from extravasation of visceral contents, in which death 
occurs so soon after the extravasation, and so little trace of inflammation 
is discernible, that it appears most probable that the fatal result was oc- 
casioned by the sinking of the nervous system. 

For the clearer explanation of the principles to be followed in the 
management of wounds of the abdomen, it is convenient to arrange them 
into four classes — 1st. Wounds which simply penetrate the cavity with- 
out injuring any of its contents ; — 2dly. Wounds which not only pene- 
trate the cavity, but injure some of the contained viscera, without pro- 
trusion of the w T ounded part ; — 3dly. Wounds attended with protrusion 
without any wound of the protruded part ; and, 4thly. Wounds accom- 
panied not only with protrusion, but also with injury of the protruded 
part. 

1st. Wounds which simply penetrate into the abdominal cavity are 
the least dangerous ; yet if the wound be extensive there is risk of its 
giving rise to peritoneal inflammation. The great object of treatment, 
therefore, is to guard against this occurrence, for which purpose abso- 
lute rest and the sparing use of the mildest ingesta should be strictly 
enjoined, together with the best local treatment for procuring adhesion, 
— comprehending attention to position, the use of adhesive plaster for 
keeping the edges of the wound in apposition, and if necessary, the 
interrupted suture. Sutures should not be employed unless absolutely 
necessary ; and when their use is ventured upon, special care is to be 
taken not to include the peritoneum in the suture. All judicious and 
available means should be employed to prevent inflammation, and if it 
should occur, appropriate remedies should be used to subdue it, such as 
low diet, perfect quiet and rest, venesection, calomel and opium, fomenta- 
tions, mild enemata, and if it can be conveniently employed, the warm 
bath. 

2dly. Wounds which not only penetrate the cavity, but also injure 
some of the contained organs' without protrusion of the wounded part, 
are extremely dangerous, and it is in many instances quite impossible 
to form an idea of the extent of injury received. The healing of the 
wound in the parietes should be promoted by suitable means, and as 
searching for the inward viscera would be contrary to all sound princi- 
ples of surgery, the symptoms arising from the internal injuries can 
only be met by medical treatment. Important indications are, to guard 
against all exciting causes of extravasation, either of blood or of visce- 
ral contents, and against all causes of inflammation; and if inflammation 



WOUNDS OF THE ABDOMEN. 509 

should occur to endeavour to subdue it by proper treatment. It is, there- 
fore, necessary to abstain from all imprudent exhibitions of stimuli for the 
removal of the collapse consequent on the injury, to preserve the body 
in perfect rest in the horizontal position, to enjoin the use of the mildest 
ingesta, and to abstain from the employment of purgatives, as being 
calculated, until the injury has been healed, to do harm not only be- 
cause, by the irritation they produce, they increase the danger of the 
occurrence of inflammation, and its intensity when it does occur, but 
also, because by the additional peristaltic motion they increase the risk 
of extravasation of intestinal contents, and interfere with the process 
by which nature repairs the injury. These, with all the details of anti- 
phlogistic regimen, constitute important parts of the preventive treat- 
ment : and when inflammation occurs, the remedies proper for that state 
must be promptly applied. If there be reason to suspect injury of the 
bladder, the catheter should be kept introduced to diminish the chances 
of extravasation of urine. 

3dly. Wounds attended with protrusion without injury of the pro- 
truded parts. The protruded parts are usually portions of intestine or 
omentum, or both ; and if uninjured, the sooner they are reduced the 
better ; but all proceedings for that purpose should be conducted with 
the utmost gentleness, so as not to induce the clanger of inflammatory 
accession, care also being taken, as in hernia, to return that part first 
which was last protruded, — the mesentery before the intestine, and the 
intestine before the omentum. By these proceedings the parts are 
more likely to resume their natural position in the belly, and there is 
less danger of exciting irritation and inflammation, than by attempting 
to return the whole en masse. Eor facilitating reduction, the patient 
should be placed in the most favourable position for the relaxation of 
the abdominal muscles ; the pelvis should be slightly raised, and the 
chest bent a little forwards. It is an important precaution, to make 
sure that the reduction is complete, lest if part of the protrusion be 
not sent into the cavity, but remain embraced by some of the textures 
forming the aperture, strangulation should ensue. It has happened in 
some cases where reduction was erroneously supposed to be complete, 
that the inner part of the wound had so embraced a portion of the pro- 
trusion, as to cause fatal strangulation. Considerable difficulty is some- 
times experienced in accomplishing reduction, in consequence of the 
protruded intestine becoming distended with flatus. Various proceedings 
have been recommended and adopted for overcoming this difficulty. 
Pare', Dionis, and many others advised the puncture of the intestine 
with a round needle to allow the flatus to escape ; some recommend 
squeezing back the air into the portion of intestine within the abdomen ; 
but the safer, and indeed, in my opinion, the only justifiable course, 
when necessary, is, instead of puncturing the intestine, or injuring it by 
undue and dangerous pressure or handling, to enlarge the opening very 
slightly. When' such a step is absolutely necessary, the incision 
should be made at the upper rather than at the lower part of the wound, 
except when the incision in that direction might endanger the internal 
epigastric artery, or correspond with the umbilicus ; and in all instances 
it should be as limited as possible. The object of both these recom- 
mendations is to diminish the danger of ventral hernia afterwards ; as 



510 WOUNDS OF THE ABDOMEN. 

the pressure of the intestines towards the upper is less than towards the 
lower part of the abdomen. Of course, if by gentle and safe pressure 
the intestine can be reduced or its contents be so returned as to admit 
of reduction, no judicious surgeon would venture on the use of the knife. 
The best instrument for enlarging the opening is the probe-pointed 
bistoury. Immediate reduction, the greatest gentleness of proceeding, 
the avoiding all unnecessary and severe handling of, or pressure on, 
the intestine, the enlarging the aperture when absolutely necessary, 
the making sure that the reduction is complete, the retaining the parts 
in the abdomen by suitable treatment until the wound is completely 
healed, and the guarding by all judicious precautions against the occur- 
rence of inflammation, are the most important points to be attended to 
in the management of the species of injury now under consideration. 

It is curious to observe the opinions which have been entertained 
regarding Park's proceeding of puncturing the intestine. It was ap- 
proved of by Dionis, Rousset, Garengeot, Van Swieten, Chopart, De- 
sault, Richerand, Lowe, Sharp, and others. These all agreed in sanc- 
tioning the proceeding, but differed among themselves as to the circum- 
stances in which it should be considered justifiable, and also as to the 
preferable form of instrument for effecting the puncture ; some using 
a broad triangular needle, some a round needle, and some as Richerand 
a trocar and canula similar to that employed in hydrocele. The pro- 
ceeding is strongly objected to by Sabatier, La Faye, Blancard, Cal- 
lisen, Travers, and almost all the higher surgical authorities in Britain ; 
some objecting that a small puncture is insufficient to insure the escape 
of the flatus, in consequence of the tendency to protrusion of the mucous 
membrane ; and others, that the proceeding is dangerous as well as ineffi- 
cient. 

4thly. Wounds accompanied with protrusion, and also with injury of 
the protruded parts. Since the special rules applicable to the manage- 
ment of wounds belonging to this class are precisely the same as those 
for the treatment of the cases of hernia in which the protruded parts 
are found, in cutting down upon them, to be in an unfit state to be re- 
turned into the abdomen, it is scarcely necessary to do more than refer 
to the section on that subject, and to that on the anatomy and treatment 
of abnormal anus. The following observations by Mr. Travers will be 
perused with interest. 

" If a gut be punctured, the elasticity of the peritoneum, and the 
contraction of the muscular fibres, open the wound, and the villous or 
mucous coat forms a sort of hernial protrusion, and obliterates the aper- 
ture. If an incised wound be made, the edges are drawn asunder and 
everted, so that the mucous coat is elevated in the form of a fleshy lip. 
If the section be transverse, the lip is broad and bulbous, and acquires 
tumefaction and redness from the contraction of the circular fibres 
behind it, which produces, relatively to the everted portion, the ap- 
pearance of a cervix. If the incision be according to the length of the 
cylinder, the lip i3 narrow, and the contraction of the adjacent longitu- 
dinal fibres, resisting that of the circular fibres, gives the orifice an oval 
form. This eversion and contraction are produced by that series of 
motions which constitutes the peristaltic action of the intestines." 



WOUNDS OF THE ABDOMEN. 511 

If the wound be very small, consisting of a mere puncture, and more 
especially if it be at a part of the canal usually not much distended, 
the most advisable course probably is to return the part, and trust to 
nature's process for closure ; in short, the treatment is replacement 
without mechanical union. 

If the wound be incised, and small, and the intestine otherwise quite 
free from injury, the edges should be brought together by a single stitch 
of silk or fine thread introduced by means of a small round sewing- 
needle, the edges being slightly turned inwards so as to have peritoneal 
surfaces in apposition. The ends of the silk should be cut off quite 
close to the knot, and the intestine replaced ; — experiments on animals, 
and experience in the human body proving that the small noose finds 
its way into the intestinal canal by ulcerative absorption, and is voided 
with the faeces. Permanent closure of the wound, in cases which pro- 
ceed favourably, is effected by the assistance of surrounding textures, 
to which the peritoneal coat of the bowel becomes adherent. The ex- 
ternal wound should not be very firmly closed at first, lest extravasation 
should take place, and the dressings should be as light as possible. In 
this variety the treatment consists both of mechanical treatment and 
replacement. 

If the wound be not very small, the most judicious procedure is to 
retain the cut portion at the surface of the wound by one or more 
stitches connecting the edges of the wound in the intestine with those 
of the external wounds, and to endeavour to convert the case into one 
of abnormal or artificial anus ; — -replacement would be extremely in- 
jurious, by incurring the danger of extravasation of intestinal contents. 

It will be seen that, in the first of the three classes into which we 
have arranged wounds accompanied with protrusion and injury of the 
protruded parts, the treatment at first consists of replacement without 
mechanical union ; in the second, of mechanical union and replacement ; 
and in the third, there is neither mechanical union of the edges of the 
wound nor replacement, but the lips of the wound of the intestine are 
retained at the margin of the external wound, and the case is converted 
into one of abnormal anus, to avoid the danger of fatal extravasation 
into the peritoneum. 

The above are the proceedings which, on the whole, appear to be the 
most judicious in the treatment of the different varieties of wounds in 
the intestine, and they are recommended by the great majority of 
British authorities of the present day. They are very different, how- 
ever, from many of the singular modes of procedure adopted formerly 
by many surgeons, and still practised by some. In some cases, liga- 
tures have been employed in great numbers ; in others, sutures of every 
possible form have been used ; most extensive wounds of the intestine 
have been sewed up, and replacement effected ; in some instances, the 
ends of the ligatures have been cut off, the ligatures having been em- 
ployed only for preserving apposition of the edges of the wound in the 
intestine ; and in others, the ends have been left and kept in the ex- 
ternal wound, the ligatures being used partly for procuring apposition 
of the edges of the wound of the intestine, and partly for keeping that 
wound near the external one. The methods of Reybard, of Palfyn, of 



512 



PARACENTESIS ABDOMINIS. 



Jobert, of Ramdohr, 1 of Duverger, and of Sabatier, are some among the 
many which have been proposed ; but as they have never gained the 
favourable opinion of the most eminent surgeons in this country, it is 
considered unnecessary to describe them. Much valuable information 
regarding these injuries will be found in the writings of John Bell, Dr. 
Thomson, Sir Astley Cooper, Dr. Hennen, and Mr. Travers, as well 
as in the works of many of the best Continental authorities on surgery. 



PARACENTESIS ABDOMINIS. 

The usual conditions which warrant the performance of this operation 
are, either ascites, or ovarian dropsy, when either disease arrives at so 
advanced a stage, that the pressure on the diaphragm creates a difficulty 
of breathing, — the object of the operation being to relieve the breathing. 
The most convenient attitude for the patient to be placed in is the 
sitting posture, on a chair, or on the side of a bed ; and the preferable 
site for the operation is the linea alba, a little below the umbilicus. 
At one time the operation was performed in the linea semilunaris, but 
as there is danger there of wounding the internal epigastric artery, the 
former situation is to be preferred. In cases, however, of ovarian 
dropsy, the pointing of an ovarian cyst may render it necessary to 
select as the site of the operation the part where the bulging of the sac 
is perceptible. The patient having been placed in the proper position, 
and a broad bandage or sheet having been applied round the abdomen, 
and the ends committed to assistants for the purpose of drawing them 

Figs. 1 70-172. 




to keep up pressure while the fluid is being drawn off, the surgeon in- 
troduces the trocar and canula through the abdominal parietes in the 
linea alba, about midway between the umbilicus and the pubes, then 
withdraws the trocar, and when the fluid has escaped through the 

1 That of invagination, as it has been called. 



PARACENTESIS ABDOMINIS. 513 

canula, withdraws it also. A piece of adhesive plaster is then placed 
over the wound, a compress above it, and the whole belly is tightly 
bound up by the bandage. The bladder should be emptied before the 
operation, that there may be no danger of wounding it ; and, while the 
fluid is being drawn off, constant pressure should be kept up by means 
of the bandage, lest dangerous or fatal syncope should result from the 
sudden accumulation of blood in the abdominal veins on the removal of 
the support previously afforded by the fluid ; or lest, from sudden dis- 
tension through the same want of support, either one of these veins, or 
some other vessel, should give way. 



28 



514 



CHAPTER XV. 

CALCULOUS DISORDEKS. 

Or the various morbid conditions of the urine, none are of greater 
interest to the surgeon than those in which various deposits take place. 
When a deposit takes place subsequently to the expulsion of the urine 
from the bladder, it is termed sediment ; when previously, gravel. 
The more remarkable diatheses connected with these deposits are the 
following : — 

I. THE LITHIC DIATHESIS. 

Varieties. — The lithic or uric acid deposit may be said in general 
to assume one or other of two distinct characters, namely, that of 
amorphous and impalpable sediment, or that of crystallized or massive 
concretions. Each of these two general divisions presents three va- 
rieties. 

The amorphous and impalpable sediment consists chiefly of lithic acid, 
in combination with ammonia. The three varieties of this deposit are 
the yellow sediment, consisting of lithate of ammonia, more or less 
tinged with the yellow colouring principle of the urine — the red, or as 
it is often called, the lateritious sediment, consisting of lithate of am- 
monia, combined with the yellow colouring principle of the urine and 
the red or purpurate of ammonia — and the pink sediment, the appear- 
ance presented when the lithate of ammonia is combined with the red 
colouring principle, with little or no admixture of the yellow. Strongly 
marked examples of this last variety are extremely rare. 

The crystallized or massive deposit is found in three varieties, — as 
crystallized sand or gravel, as amorphous concretions, or as pisiform 
concretions. 

Crystallized sand or gravel, consisting of lithic acid with purpuric ad- 
mixture, is of various forms and colours, according to the 
Fig. 173. nature of the urine from which it is deposited. These 
crystals to the naked eye much resemble in size and shape 
the particles of Cayenne pepper, and in colour, when their 
presence is accompanied by fever, they are usually reddish ; 
when without fever, they more or less resemble the yellow 
amorphous sediment. [Under the microscope the crystals 
present the appearances represented in the wood-cut. 
—Ed.] 

The amorphous lithic concretions present two varieties, 
the coloured and the white. The former, which are the 
\I^> \v\\ more common, consist almost entirely of pure lithic acid, 
and are irregular in form, generally rough on the surface, 




CALCULOUS DISORDERS. 515 

and not crystallized within, but appearing as if formed by many different 
masses being pressed together ; in colour being sometimes yellow, some- 
times of a dark brown or brownish red. The latter or white variety, 
consisting of lithate of soda, are extremely rare, irregular in shape and 
size, soft in texture, and presenting neither a crystallized nor lamellated 
appearance, but amorphous. 

The pisiform lithic concretions are in most instances generated in 
great abundance, and vary in size ; in form they are more or less globu- 
lar ; their surface is smooth, in many instances remarkably so ; their 
central parts usually lamellated, and almost invariably crystallized. 
Their colour varies considerably, being sometimes, although rarely, a 
dark brown or reddish, but more commonly one or other of the shades 
of yellow. 

Both the amorphous and pisiform lithic concretions are usually gene- 
rated in the kidney, and they are much more formidable than the other 
varieties of lithic deposits, inasmuch as there is great risk of their origi- 
nating the formation of calculi. When lithic deposits take place in old 
age, they are usually the pisiform. 

Causes. — The tendency to lithic deposit is hereditary. It is usually 
found either in children and young persons under the age of puberty, or 
in persons from forty to sixty years of age. 

The principal exciting causes are, errors in diet, want of sufficient 
exercise, waste of tissues more rapid than the supply, as in fever, ne- 
glect to maintain a clean and proper state of the skin, and atmospheric 
influence. The habitual use of too much food, especially of animal 
food, the use of wines or malt liquors, or of any kind of food or drink 
calculated to produce an excess of hydrochloric acid in the stomach, a 
cold and moist condition of the atmosphere, or such a state either of the 
atmosphere or of the skin as tends to prevent the customary evolution 
of free acid or nitrogenized excretion through the skin, and certain cu- 
taneous diseases, are favourable to the formation of lithic deposits. 
Free acid generated in the stomach passes off by the urine, and com- 
bining with an alkaline base precipitates the lithic acid. 

Dr. Prout remarks, "The lithic acid and its compounds we suppose 
to be principally derived from the albuminous principles, not only of the 
chyle and blood, but also of the albuminous textures of the body, in 
the same sense and mode in which we suppose urea and lactic acid to 
be principally derived from the gelatinous textures. When, on account 
of the imperfect assimilation of alimentary matters by the stomach and 
primary assimilating processes, the chylous principles are not raised to 
that standard of perfection by which they are fitted to become compo- 
nent parts of the blood, we suppose that the healthy kidney possesses 
the power of selecting and disorganizing such imperfectly developed 
chylous matters, and of converting them into lithate of ammonia. Such 
is the presumed origin of most of the yellow amorphous sediments occur- 
ring to healthy individuals from slight errors in diet, &c. 

" During feverish or other derangements, in which the functions of 
the hepatic system are particularly involved, the lithate of ammonia is 
not only supposed to be derived from the imperfectly assimilated chyle, 



516 CALCULOUS DISORDERS. 

and the deteriorated albuminous principles of the blood ; but also from 
the deranged secondary assimilation of the albuminous textures of the 
body. The lithate of ammonia thus developed appears in the urine 
more especially under the forms of the red and pink amorphous sedi- 
ments ; and is distinguished by the large quantities of colouring matters 
developed in conjunction with it. Lastly, the massive forms of lithic 
acid deposits are derived from the same sources as the above ; but when 
thus deposited, the lithic acid is secreted, either in connexion with acids 
which combining with the ammonia of the lithates set the lithic acid 
free ; or in connexion with other bases, as soda, &c, the compounds of 
lithic acid with which are less soluble than the lithate of ammonia." 

Treatment. — Indolence and inactivity being predisposing causes of 
lithic deposits, exercise, judiciously proportioned to the strength of the 
patient, and not sufficient to induce fatigue, should be strictly enjoined. 
The state of the skin should be attended to, and with that view bathing 
and friction are useful ; the clothing should be sufficiently warm to pre- 
vent the natural and healthy perspiration from being checked, and if 
possible, residence in a cold and damp situation should be avoided. 
Attention to diet is of the greatest importance, and in reference to this 
part of the treatment, the patient should be cautioned to avoid all kinds 
of food and drink which are indigestible, or calculated to excite acidity. 
Malt liquors of all kinds are injurious ; wines, especially the sweet and 
acescent, and hard waters, should be avoided. Animal food should be 
taken but sparingly ; and it is most important that the food generally 
be not only of the most digestible kind, so as not to excite derangement 
of the stomach, but also that it be taken in very moderate quantities. 
Besides, attention to exercise, to the state of the skin, and to the careful 
regulation of diet, all which are important for diminishing the tendency 
to the occurrence of lithic deposit, it is advisable to administer alkalies 
for the purpose of preventing the formation of the lithic acid or of neu- 
tralizing it, and also for preventing its precipitation and the consequent 
danger of aggregation, by offering a soluble base for the acid. Of the 
different alkalies, potass is by much the preferable, as the salts formed 
by its combination with lithic acid are soluble ; whereas with soda a salt 
may be formed as insoluble as lithic acid itself. 

II. PHOSPHATIC DIATHESIS. 

This term does not imply the mere presence, or any excess, of the 
phosphates in the urine. In the healthy condition of that secretion, the 
earthy phosphates are eliminated from the body in a state of solution ; 
but in certain states of constitution the balance of the healthy affinities 
is broken, and the phosphates become deposited in a visible form. To 
this condition is given the title of phosphatic diathesis. 

In the uric acid diathesis, the gravel precipitated is red, whereas in 
the phosphatic, it is white. In the former, the deposit of lithate of am- 
monia is determined by an excess of acid ; in the latter, by deficiency 
of acid, or alkalescence of urine. This class of deposits consists of, 1st. 
The triple phosphate of magnesia and ammonia. 2d. The phosphate 



CALCULOUS DISORDERS. 517 

of lime (an exceedingly rare variety) ; and 3d. Of a mixture of the two 
former. 

The earthy phosphates are readily soluble in urine healthily acid, and, 
therefore, an excess of them may pass off in acid urine without becoming 
visible ; whereas the minutest quantity becomes visible in alkaline urine, 
on account of their not being soluble in alkaline fluids. Urine may be 
alkaline from the formation of a fixed alkali, such as the carbonate of 
soda, the carbonate of potass, or the alkaline phosphate of soda ; but 
more commonly from the presence of ammonia, constituting what has 
been called ammoniacal urine, the ammonia being endangered by the 
decomposition of urea. Phosphate of magnesia is contained in healthy 
urine, but it is very soluble. If, however, ammonia be engendered, the 
triple phosphate of ammonia and magnesia which is formed, is insoluble. 
This triple phosphate may either be precipitated in the form of white 
crystals, or it may have an amorphous character. [In Fig. 
174 the various forms which the triple phosphate exhibits 
under the microscope are represented. Generally the 
crystals are sections of a prism ; sometimes they have a 
stellar, foliaceous, or penniform arrangement. — Ed.] Of 
the three deposits above mentioned, the first is the least 
formidable ; the second, as has been already stated, is ex- 
tremely rare ; the third, consisting of a mixture of the two 
salts, is by far the most frequent, and is also the most for- 
midable. 

Causes. — The predisposition to the deposit of the earthy 
phosphates is inherited. The exciting causes act, some generally, 
others locally ; the principal are, long-continued over-exertion, de- 
pressing passions, insufficient food, the habitual or long-continued 
use of debilitating medicines, such as mercury or strong purgatives, 
the abuse of the alkaline medicines, injuries of the kidneys, organic 
disease of the kidney, bladder, or prostate gland, and injuries or a 
morbid condition of the spinal cord. Any influence which unfavoura- 
bly affects the body generally may be an exciting cause. It is well 
known that alkaline deposit is often found in consequence of injury 
of the back, a fact which was pointed out by Sir Benjamin Brodie, 
as far back as 1&07. On this subject an excellent authority remarks, 
"The immediate link in the chain of connexion between the cord 
and the urine in these cases, seems commonly to be a chronic inflam- 
matory condition of the mucous membrane of the bladder, the decompo- 
sition of urea being effected by the altered mucus." When urine is 
alkalescent from a fixed alkali, no ammonia being present, then instead 
of the triple phosphate of ammonia and magnesia, the phosphate of lime 
is thrown down, and may present itself as a fine white sand, or as a film 
of iridescent appearance on the surface of the urine. 

Symptoms. — The urine depositing the triple phosphate is generally 
abundant, pale-coloured, of low specific gravity. That depositing phos- 
phate of lime has been found in a few instances of a deep colour and 
acescent when passed, but usually it is of a pale colour, of a low or mo- 
derate specific gravity, and becomes alkalescent sooner than healthy 




518 CALCULOUS DISORDERS. 

urine. That depositing the mixed phosphates, -when unattended with 
disease of the bladder, usually is exceedingly abundant, of a pale colour, 
of a low specific gravity ; and although it may be clear when passed, 
yet on being exposed to heat it becomes turbid from deposit of the 
phosphates ; when connected with diseased bladder, it is usually alka- 
lescent on being passed, and invariably becomes so on cooling ; it also 
becomes very offensive, and with the phosphates deposits large quanti- 
ties of mucus sometimes tinged with blood. Often, and especially in an 
advanced stage of. the disease, the local and constitutional symptoms 
attending the phosphatic diathesis, resemble those of disease of the 
bladder, or of some other organic disease. The constitutional symp- 
toms are subject to considerable modifications ; but in all instances 
where the disease has assumed a permanent character, patients are ca- 
chectic, weak, sallow, languid, sleepless, and much affected with ner- 
vous irritability, which is evinced in many different ways. The bowels 
are flatulent and often irregular, and the peristaltic motion accompanied 
by borborygmi, and patients complain of a feeling of sinking and of pain 
and weariness in the back and loins on making the least exertion. 

Treatment. — In this diathesis the powers of life being in an asthenic 
condition, the treatment indicated by that condition is what experience 
has shown to be the most useful, and consists in the use of a generous 
animal diet, tonics, the mineral acids, such as the nitric or muriatic — 
both of which in many cases are given with great advantage — the due 
regulation of the bowels when absolutely necessary, by the very mildest 
aperients, freedom from care and mental anxiety, and from every kind 
of exertion calculated to produce an unfavourable impression on the 
body, exposure to a free bracing atmosphere, and together with these 
means, the use of sedatives, which are peculiarly indicated by the ner- 
vous irritability and anxiety with which patients in this state are so 
often afflicted. Of all remedies belonging to this class, opium is the 
most valuable, not only from its effects in relieving nervous irritability, 
but also from its power of rendering alkaline urine acid. In the severe 
forms of this disease opiates are necessary, and the preparation which 
experience has shown to be the most useful is the liquor opii sedativus 
of Battley. 

The above are the principal indications of treatment ; and when they 
are attempted to be fulfilled, the means must be modified according to 
the particular circumstances of individual cases. Saline draughts, alka- 
line medicines, saline or reducing purgatives, mercury, malt liquors, 
acescent vegetables, hard waters, and fruits, are injurious and ought to 
be avoided. 

III. OXALIC DIATHESIS. 

In this diathesis the preponderating unnatural ingredient in the urine 
is oxalic acid ; and there is a tendency to the formation of calculus of 
oxalate of lime in the kidney, if a nucleus exist. 

Symptoms. — The distinctive characters of the urine in this diathesis 
are, that it is remarkably free from sediment, often bright and clear, 
but sometimes of a pale citron yellow or greenish hue, and of low or 



CALCULOUS DISORDERS. 519 

moderate specific gravity, and if condensed by evaporation, or examined 
by the microscope, the characteristic octohedral crystals are 
discernible. [Occasionally, small masses are found resem- Fl S- 175 - 
bling dumb-bells. — Ed.] This diathesis is met with both ^k 1 A\ 
in the young and the old ; but the mulberry calculus is most w 

commonly found in the middle period of life, and in the *^ * 
dyspeptic, and in persons of the sanguine and the melan- ^r Q 
cholic temperaments. The constitutional symptoms vary ^ 
exceedingly in character and degree, and in some respects ^ 
are influenced by the peculiarities of temperament of the ||| 
patients ; those of the sanguiue temperament being irritable, 
and those of the melancholic desponding and dejected ; the |T| 
mind having a great tendency to brood over the symptoms 
of the disease. Uneasiness is experienced during the assimilation of 
the food ; flatulence is complained of, the symptoms of dyspepsia are 
often very troublesome, and in many instances the patient is annoyed 
by palpitation. When the diathesis is very marked, the skin in some 
cases assumes a peculiar hue. On this subject Br. Prout says, "The 
skin is apt to assume an unnatural appearance difficult to describe, but 
the colour of which may be said to vary from dull greenish yellow in 
the sanguine, to dark olive or livid in the melancholic temperament." 
A nephritic attack occurs, and if the patient get rid of the calculus, he 
usually remains for years free from all his uncomfortable symptoms. 
The oxalate of lime calculus, which forms during the continuance of the 
diathesis, is hard, and bears a striking resemblance in form and colour 
to the mulberry, and is hence called the mulberry calculus. In some 
instances small calculi, consisting of oxalate of lime, are found bearing 
so close a resemblance to hemp seed, that they have been designated 
hemp-seed calculi. If they be not carried off by the urine, they pass 
into the mulberry calculus. 

Although the mulberry calculus is not common, Dr. Golding Bird has 
found that small crystals of oxalate of lime are extremely common in 
the urine, and are discoverable by the microscope, although they do not 
sink or form a deposit. In slight cases there may be no local or consti- 
tutional symptoms, or none sufficiently marked to attract attention, the 
presence of the diathesis is then discoverable only by the microscope. 

Causes. — Some of the exciting causes of this diathesis are believed to 
be grief, depressing passions, great loss of blood, and residence in a 
damp and malarious situation. It has been known to follow gout, and 
to accompany chronic rheumatism. Dr. Prout says, "Diet under all 
circumstances, but particularly in strongly predisposed habits, has, per- 
haps, more influence in exciting this diathesis than any other cause. I 
have seen repeated cases in which the too free use, or rather abuse, of 
sugar has given occasion to the oxalic acid form of dyspepsia; and 
sooner or later, under favourable circumstances, to the formation of an 
oxalate of lime calculus. I have also seen, as before noticed, well- 
marked instances in which an oxalate of lime nephritic attack has fol- 
lowed the free use of rhubarb (in shape of tarts, &c), particularly when 



520 CALCULOUS DISORDERS. 

the patient has been in the habit, at the same time, of drinking hard 
water." 

Treatment. — The treatment consists principally in attention to diet, — 
promoting the due performance of the functions of the digestive organs 
and of the skin, and in the observance of all judicious and proper means 
for maintaining the general health and strength. The diet should con- 
sist of animal and farinaceous food, and as the assimilating process is 
weakened, even those things which are proper, should be taken in very 
moderate quantities, and in the lightest and most digestible form. The 
safest drink is distilled water. If, on account of the habits or condition 
of the patient, some stimulant should be necessary, brandy and water, 
taken with food, would be preferable to wine. The condition of the 
bowels must be carefully attended to, and, when necessary, regulated 
by the mildest laxatives ; the function of the skin must be promoted 
by sponging, friction, and suitable clothing ; and all causes of exhaus- 
tion or depression carefully avoided. Of medicinal remedies, the mine- 
ral acids, such as the nitric or the muriatic in some tonic infusion, and 
the nitro-muriatic in some bitter infusion have been found of the greatest 
service. The effects of the mineral acids must be watched, and their 
use discontinued when they begin to produce a deposit of lithic acid, or 
of lithate of ammonia in the urine. On this subject, a great authority 
expresses himself as follows: — "In cases of this diathesis, when the 
patient lives at a distance in the country, I commonly recommend the 
use of the muriatic acid, or nitro-muriatic acid, as the case may be, 
to be persisted in till the lithate of ammonia, or the lithic acid, begins 
to appear in the urine ; or for a month, and by adopting such a course 
of acids three or four times in the year, and by a carefully-regulated 
diet, I have seen the diathesis gradually subdued, and at length removed 
altogether." It is of the greatest importance for persons who have this 
diathesis, to abstain from sugar, fruits, fermented liquors, all kinds of 
viands containing oxalic acid, and especially the stalks of rhubarb, and 
from hard water. By partaking of food containing oxalic acid, and of 
hard water, which contains the supercarbonate of lime, they would be 
introducing into their system the very ingredients of the mulberry cal- 
culus. 

URINARY CALCULI. 

Urinary calculi are formed on nuclei of their own substance, or on a 
clot of blood or mucus, or on some foreign substance introduced into the 
bladder by the urethra, or in consequence of a wound, or of ulceration. 
They may be either renal, or vesical. 

CALCULUS IN THE KIDNEY. 

The primary nucleus of a renal calculus may be constituted by the 
simple cohesion of the deposit, or by a clot of blood, or by a particle of 
the epithelium of the mucous membrane lining the cavities of the kid- 
ney — this last being a mode of origin believed to be not unusual after 
injury or inflammatory attacks of the kidney. 

[Ilenal calculi are generally composed of uric acid, although occa- 
sionally they are formed of the oxalate or phosphate of lime. Their size 



CALCULOUS DISORDERS. 



521 



and form is very various. They may be as small as a grain of sand, or 
they may be so large as to prevent their escape from the kidney by the 
ureter. 

Remarkable specimens of this kind were obtained by the editor, a few 
years since, from a little girl twelve years of age. The kidneys were 



Fig. 176. 



Fiff. 17 





much enlarged, and the pelvis, calices, and infundibulse greatly dis- 
tended by the calculi. The parietes were so thin, and the structure so 
altered that none of the characteristic appearances of the gland could 
be observed. When removed from the loins they felt like membranous 
sacs filled with stones. Upon fitting together the fragments they pre- 
sented the arborescent figures of the actual size and form represented in 
the wood-cuts, with numerous stems and buds, forming a cast of the 
dilated cavities of the kidney. The buds, or the enlargements corre- 
sponding with the infundibula, were composed of clusters of beautiful 
shining crystals. Dr. Bridges analysed them, and found them to be 
composed of the phosphate of lime. Their weight was five hundred and 
ten grains. 

The presence of these calculi was not suspected before death, although 
the sandy and ropy character of the urine, and the pain in the lumbar 
regions, gave indications of nephritic disease. The child died from 
hectic produced by inflammation of the kidneys. 

In some few instances the stone has created an abscess in the kidney, 
and has been discharged through the loins. 



Figs. 176, 177, 
July, 1849. 



Renal Calculi. From Dr. Neill's paper in the American Journal, 



522 CALCULOUS DISORDERS. 

The affection may be considered a slow and painful one ; and if it 
occur on both sides, producing inflammation of the kidneys, would likely 
prove fatal. 

Yet a person may carry a small stone in the kidney for some time 
and feel no pain ; but if, from some exertion, the stone be broken, or 
change its position, the pain would be severe, and extend to the groin. 

When the stone is so small as to escape from the pelvis of the kidney 
and descend the ureter, it gives rise to those painful and distressing 
symptoms frequently spoken of as a fit of the gravel. 

The symptoms are more severe when the stone is rough and large, and 
they continue as long as the stone is passing along the ureter, which 
may occupy from twelve to forty-eight hours. The pain commences in 
the loins, and extends to the groin and testicle, which is generally re- 
tracted. The patient suffers from sick stomach, and often vomits. At 
the same time there is prostration, the skin becoming pallid and covered 
with cold perspiration. The symptoms generally subside suddenly, 
owing to the entrance of the calculus into the bladder, but Sir Astley 
Cooper records several cases which terminated fatally, owing to the 
stone completely filling up the ureter, which became much distended 
with urine and pus. In one instance the ureter burst, and the contents 
were discharged into the abdomen. 

Treatment. — Should a stone be diagnosticated in the kidney, it would 
be important to determine the diathesis of the patient, and to prevent 
the increase of the deposit by such remedies as have already been pointed 
out. At the same time its escape from the kidney is to be promoted by 
diluents and diuretics. But should it be too large to pass, and give pain 
by exciting inflammation of the kidney, cups should be applied to the 
loins, and opiate enemata administered. 

The same kind of treatment would be required when the stone is 
passing down the ureter. If the patient be robust and vigorous he 
should be bled freely. Owing to the excessive pain, it may be necessary 
to give larger doses of opium, as well as to employ the opiate enemata. 
Relaxation of the ureter, and relief from pain may also be expected from 
the hot bath and laxative medicines. Should the stone become im- 
pacted in the ureter, it is possible that it may be discharged by ulcera- 
tion through the parietes of the abdomen. 

CALCULUS IN THE BLADDER. 

The description of urinary calculi in Dr. Gross's "Practical Treatise 
on the Diseases of the Urinary Organs," is so complete that the editor 
conceives that he cannot do better than to present a large portion of it 
to the student. 

" Stone occurs at all periods of life, from the most tender infancy to 
the most decrepit old age. Indeed, there is reason to believe that it 
occasionally exists as an intra-uterine affection. Geyer 1 relates the 
case of a boy who suffered from calculus of the bladder from birth. 
He was cut in his twelfth" year, when the stone had acquired so large 
a bulk that it had to be broken before it could be extracted. The 

1 Miscel. Nat. Curios., Dec. 11, An. V. p. 456. 



CALCULOUS DISORDERS. 523 

whole mass weighed ten ounces. Stahl 1 found a calculus of the size of 
a peach-kernel, in an infant of three weeks, that had suffered great 
distress from its birth in passing its water. Similar examples are 
mentioned by Nicolai, 2 Armstrong, 3 Richel, 4 Greding, 5 Nosaus, 6 and 
others. 

" Of 5376 cases mentioned by Civiale, in his treatise on Calculous 
Affections, 2416 were children, 2167 adults, and 793 old persons ; 1946 
occurred before the age of ten, 943 from ten to twenty, 460 from twenty 
to thirty, 330 from thirty to forty, 391 from forty to fifty, 513 from 
fifty to sixty, 577 from sixty to seventy, 199 from seventy to eighty, 
and 17 after eighty. 7 

" Children are more subject to this disease in certain districts than in 
others, and the same is true in regard to adults. The greater propor- 
tion of calculous cases in Wirtemberg, in the mountains of Switzerland, 
the Neapolitan States, and in some of the counties of England, espe- 
cially Norfolk, occurs in young persons, from causes hitherto unex- 
plained. In the United States, a larger number of children are affected 
with this disorder in Kentucky, Ohio, Tennessee, and Alabama, than in 
any other regions. Pennsylvania, Virginia, Maryland, the two Caro- 
linas, Georgia, Florida, Louisiana, and Arkansas, also furnish a consi- 
derable number of cases. The inhabitants of Missouri, Iowa, Wisconsin, 
Michigan, Indiana, New York, and New Jersey are comparatively ex- 
empt ; and in the New England States generally a case of calculus of 
the bladder is so rare as to excite the surprise of the observer. In 
Canada and the other British Provinces of North America the disorder 
is also very infrequent: at all events, none of the surgeons of these 
regions have acquired much reputation as lithotomists, and but few cases 
of stone are brought from thence into this country. We are justified, 
therefore, in believing that the malady is uncommon there. The same 
remarks are applicable to Texas, Mexico, and California, as I have 
assured myself by repeated inquiries from respectable and intelligent 
practitioners in those territories. The causes of these differences have 
not been ascertained ; attempts have been made to trace them to the 
effects of climate, and to the influence of the water, food, and habits of 
the people, but without success. 

" It is not satisfactorily ascertained whether this affection is hereditary. 
Facts certainly warrant the inference that it is. Thus, Civiale relates 
the case of a man on whom he practised lithotrity, whose mother had 
had stone, and one of whose children died of it. He also performed 
the operation on two brothers, whose grandfather and two uncles had 
laboured under the disorder. Prout speaks of a family in which the 
father, son, and grandson were all affected with uric acid calculi. I 
have not met with any cases illustrative of the present topic. 

1 Diss. De Morb. Foetuum in Utero Materno, S. 6. 

2 Von Erzeugung der Kinds im Mutter Leibe, Halle, 1746, p. 223. 

3 Ueber die Gewohulichen Krankheiten Regensb. 1788. 

4 Voigtel's Handbuch der Path. Anatomie, 3 B. p. 289. 

5 In Ludwigii Advers. Med. Pract. Vol. iii. P. iv. p. 742. 

6 Jour, de Medecine, T. lxxii. p. 369. 

"See tbe Author's edition of Liston's Surger} 7 , p. 531. Philad. 1840. 



524 CALCULOUS DISORDERS. 

" Coloured persons appear to be remarkably exempt from calculous 
complaints. Whether this is the case in all countries where the negro 
resides I am not informed, but it is certain that the circumstance obtains, 
in an eminent degree, in the black population of the Southwest. During 
a residence of ten years in Kentucky, I do not recollect to have met 
with a solitary example of gravel or stone in a coloured person. My 
impression is that Dr. Dudley in his large calculous practice has never 
cut more than two or three individuals of this description. To what 
this immunity is due, our knowledge does not enable us to determine. 
The circumstance is so much the more surprising when it is remembered 
that the coloured people of that region are constantly exposed to hard 
labour, and that their fare is often of the coarsest character. 

"Urinary calculi are much more frequent in men than women, because 
they are more constantly exposed to the exciting causes of the com- 
plaint; and secondly, because the more complicated structure of the 
urinary apparatus, which prevents the ready discharge of sabulous 
matter, and thus favours the formation of stone. But for the latter 
circumstance, the probability is that young girls would suffer nearly as 
often as boys. 

" What influence, if any, occupation exerts upon the production of this 
disorder, we have no statistical facts to determine. In the southwestern 
states, especially in Ohio, Kentucky, and Tennessee, the great majority of 
calculous subjects are farmers and mechanics, or the sons of persons of 
this description ; and the same is true, I suppose, of the calculous cases 
in the other states. Persons who are habitually exposed to cold and 
wet are said to be particularly prone to this complaint ; the fact, how- 
ever, if it be one, requires confirmation before it can be received as 
true. It has been already shown, as it regards sailors, who were formerly 
supposed to be very liable to stone of the bladder, that they are extremely 
exempt from it. 

" Climate, doubtless, exercises no little influence in the formation of 
urinary concretions. It has been already stated that, in the United 
States, this disease is most common in Ohio, Kentucky, Tennessee, and 
Alabama ; a circumstance which, so far as is known, does not depend 
upon any peculiarity of living, and which may therefore be supposed to 
be owing to some mysterious operation of the climate. In Holland 
calculous disorders are very common, and the circumstance is the more 
remarkable, because of the great use that is made of gin, which is a 
powerful diuretic. That this liquor is not the cause of this occurrence 
is proved by the fact that the Dutch colonists of Batavia, in the island 
of Java, whose habits are not at all dissimilar from those of the people 
of the mother-country, are almost entirely exempt from this affection. 
Soemmering informs us that the disease is altogether unknown in some 
situations bordering on the Rhine. 1 Calculous affections are, as was 
stated before, much more common in Norfolk than in any other part of 
England, and yet the habits of the residents there are the same as in 
the other counties. In the East Indies, stone is comparatively unusual, 
though not so much so as was formerly imagined. We have already 

1 Coulson on the Bladder, p. 1GG. London, 1812. 



CALCULOUS DISORDERS. 525 

seen that it is proverbially uncommon in New England. It is hardly 
safe, however, to indulge in any remarks concerning a subject which is 
involved in so much obscurity as the one under consideration. Much 
of what has been advanced is wholly conjectural, and, therefore, scarcely 
worthy of serious attention. Patient and multiplied observations in 
different parts of the world are alone competent to furnish us with any 
real and substantial light ; for these we must wait before we are justified 
in coming to any positive conclusion." 

" Many respectable writers and practitioners are of opinion that the 
production of calculous diseases is promoted by the use of hard, impure 
water, in consequence of the changes which it is supposed to induce in 
the renal secretion. The opinion is plausible, and may be true, but 
how far, or to what extent, nobody has attempted to decide. If it be 
true that in Kentucky, Alabama, Tennessee, and Ohio, most calculous 
cases occur in limestone regions, it is equally true that many are found 
in the freestone districts of those states." 1 ] 

The most frequent origin of a vesical calculus is the descent of a renal 
calculus, and its retention in the bladder. This in most instances fur- 
nishes the nucleus, which, however, sometimes originates in a drop of 
blood or of mucus. In some cases, calculi are formed on nuclei of their 
own substance deposited in the bladder ; and in others, nucleus is a fo- 
reign substance introduced into the bladder from without. In the great 
majority of instances, however, the nucleus is provided by the urinary 
organs themselves, and aggregation may go on at the original site of 
formation, or descent may take place into the bladder. The calculi that 
originate in the kidney, on nuclei of their own substance are the uric 
acid, and the oxalate of lime, but most frequently the former ; whereas 
those which originate in the bladder, on nuclei of their own substance, 
are the phosphatic, and the cystic oxide calculi. 

[" In many instances, however, the concretion is formed round a foreign 
body, introduced either by the patient himself through design or acci- 
dent, or in the same manner by a second party. A person shot in bat- 
tle has been known, at a subsequent period, to suffer from stone in the 
bladder, in consequence of the ball having lodged in that organ, and 
thus invited, as it were, a deposit of calcareous matter. A surgeon may 
become the innocent cause of a similar occurrence. In treating a dis- 
eased urethra, or in exploring this canal, the bladder, or the prostate 
gland, the catheter, bougie, or sound which he uses may break off, and 
afterwards lead to the development of a stone. Many such cases are 
upon record. A great variety of substances, as nails, tacks, bullets, 
needle-cases, fruit-stones, peas, beans, pebbles, tents, hairs, small keys, 
pipe-stems, glass tubes, grass stalks, pieces of straw, pins, and needles, 
have been accidentally lodged in the bladder, by patients endeavouring 
to relieve stricture, to procure evacuations of urine, to excite onanism, 
or create public sympathy. Examples of this kind are, for obvious rea- 
sons, more common in the female than in the male. O'Brien relates 2 
an instance in which the nucleus consisted of a human tooth ; Liston, 3 
one in which it was formed by a brass ring ; and Malago, 4 one in which 

'Dr. Gross, on Diseases and Injuries of the Bladder, p. 342-346. 

2 Dublin Journal of Medical Science for March, 1834. 

3 Edinb. Med. k Surg. Jour., vol. xix. p. 57. 4 Filiatre Sebezio, 1845. 




526 CALCULOUS DISORDERS. 

it was composed of a globule of mercury. In my private collection is a 
portion of calculus, presented to me by Dr. Jetton, of Tennessee, which 
contains three of the caudal bones of a squirrel. The man from whom 
it was removed was thirty-five years of age, and the probability is that 
he was in the habit of exciting onanism with the tail of this animal, a 
piece of which broke off, and slipped into the bladder in an attempt of 
this kind. In the annexed drawing, taken from a preparation in the 
Fi 17g cabinet of Dr. Sabine, of New York, the 

nucleus consists of a piece of cork. Dr. 
Van Buren, son-in-law of Dr. Mott, and 
one of the surgeons of the Bellevue Hos- 
pital, informs me that he has a stone, the 
nucleus of which is formed by the head of 
a stalk of wheat. It was removed from 
a man nearly seventy years of age. He 
had introduced the straw for an improper 
'*^m^^*^AM&^ purpose, and the barbs no doubt prevented 

its retraction; the consequence was that it passed beyond his reach, and 
ultimately into the bladder. 

" The nucleus varies much in its size, colour, form, and consistence. 
Although generally single, it is sometimes double, triple, and even 
quadruple : its situation is not always strictly central. The instances 
in which the concretion is hollow, or the nucleus loose, are rare. 

" Calculi vary much in their number. In general, there is only one; 
now and then there are two or three ; and sometimes, though rarely, 
there are several dozens, or even several hundred. The largest number 
I have ever found was fifty-four, which I removed from the bladder of 
an old gentleman, upwards of seventy-six years of age, from Oldham 
County, Kentucky. They were of a dull whitish colour, smooth, irregu- 
lar in their shape, and from the size of the kernel of a filbert to that of 
a common marble. Fifty-five were found in the bladder of the cele- 
brated Buffon. Examples are mentioned of sixty, seventy, eighty, 
ninety-six, and one hundred. The greatest number ever extracted by 
Sir Astley Cooper was one hundred and forty-two. Dessault took up- 
wards of two hundred from the bladder of a priest. Similar instances 
are mentioned by Kriiger, Dupuytren, and others. Dr. John Kelly, 1 
of the State of New York, has published a case of two hundred and 
twenty-eight. Tulpius, Boerhaave, Beauchene, and Ribes each record a 
case of three hundred or upwards. In the instance mentioned by the 
latter, this number was found after death in a man who had previously 
undergone the operation of lithotomy three times. Murat met with six 
hundred and seventy-eight. Schurig, in his "Lithology," refers to a 
case of seven hundred. The most extraordinary example, however, 
upon record, occurred in the practice of the late Dr. Physick, who ex- 
tracted from Judge Marshall, of the Supreme Court of the United 
States, upwards of one thousand calculi, from the size of a partridge 
shot to that of a bean. They were all of an oval shape, and marked 
each by a small black spot. 2 

1 Amer. Jour. Med. Sciences, Jany., 1847, p. 246. 

2 Gibson's Institutes of Surgery, xi. p. 220. Fifth edition. 



CALCULOUS DISORDERS. 527 

" The mulberry calculus is almost always solitary ; and the same is 
true, but not to the same extent, of the uric calculus. The phosphatic 
calculus, on the contrary, is not unfrequently multiple. When the con- 
cretions are numerous, they are always proportionably small, and more 
or less smooth on the surface, from the constant friction which they 
exert upon each other in the bladder. On the other hand, solitary 
stones are generally rough, and comparatively large. 

" The volume of urinary concretions ranges between a hemp-seed 
and a cocoa-nut. In the great majority of instances it does not exceed 
that of an almond, a pullet's egg, or a walnut, the latter of which in- 
deed it seldom reaches. In young subjects, and in recent cases gene- 
rally, the size is usually inconsiderable. I have a number of calculi, 
extracted from children from three to five years of age, which, in their 
volume, hardly equal a common marble. The size of a urinary concre- 
tion, however, does not necessarily depend upon the period of its sojourn 
in the bladder, or the age of the patient. Occasionally it increases very 
rapidly, so as to attain a considerable bulk in a very few months ; and, 
on the other hand, it may remain small for many years. In 1844, I 
operated upon a man twenty-six years old, who had laboured under well- 
marked calculous symptoms from his earliest infancy, and yet the stone 
was hardly as big as a hen's egg. 

" The chemical constitution appears to exert no inconsiderable in- 
fluence upon the volume of urinary concretions ; thus, the ammoniaco- 
magnesian and the fusible calculi are capable of attaining a very large 
size, while the uric, oxalic, cystic, xanthic, and fibrinous, are almost 
always comparatively small, no matter what may be their own age or 
the age of the patient. This fact is interesting in a practical point of 
view ; because, by ascertaining the calculous diathesis of the sufferer, 
we shall be able to form a tolerably correct idea as to the volume of the 
stone under which he is labouring. 

" It has been already seen, that when urinary calculi coexist in great 
numbers, they are always proportionably small. In the most remarka- 
ble case of this kind upon record, — that of Judge Marshall, previously 
referred to, — the size of none of the concretions, which amounted to 
upwards of one thousand, exceeded that of a bean, while many of them 
were not larger than a partridge shot. It is worthy of remark also, that 
under these circumstances, the individual calculi are generally of un- 
equal dimensions. 

" The consideration of the weight of urinary concretions is necessa- 
rily connected with that of their volume. In general this does not ex- 
ceed a few drachms or ounces. Out of every one hundred calculi, as 
they occur in the cabinets of different institutions, or private individuals, 
few will be found to weigh more than five or six drachms. The smallest 
probably ever removed by operation was one of ten grains, extracted by 
Mr. Martineau, of Norwich, England, from a boy thirteen years old. 
Many examples,- however, are recorded of four, six, eight, ten, twelve, 
fifteen, and even sixteen ounces. Instances of eighteen, nineteen, and 
twenty ounces, are related by Borellus, Lusitanus, Cheselden, Pauw, 
Foschini, Wrisberg, and Sandifort. Fabricius Hildanus describes a 
calculus which weighed twenty-two ounces, and was four inches and a 



528 CALCULOUS DISORDERS. 

half in length, by three and a half in breadth. Examples of from 
twenty-four to thirty ounces are recorded by Deschamps, Pauw, Paget, 
Tolet, King, and other authors. In the case mentioned by the latter, 1 
the patient, who was forty-six years of age, had suffered from his in- 
fancy, and the stone was seven inches and a half long, by fifteen inches 
in circumference. Several instances exist in which the concretion 
weighed thirty-five, forty, forty-five, and even fifty ounces. Mr. Henry 
Earle, 2 of London, has published the particulars of a calculus which 
weighed forty-four ounces, and was sixteen inches in circumference. It 
was impossible to break it, and the operator was compelled to leave his 
task unfinished. Deschamps gives a case of fifty-one ounces ; Verduc, 
one of three pounds three ounces ; and, as if to cap the climax, Kessel- 
ring 3 one of upwards of six pounds. 

"Not a little diversity obtains in respect to the consistence of vesical 
concretions. As a general rule, it may be said to vary from that of 
semi-concrete mortar, chalk, or wax, to that of stone or marble. The 
hardest calculi are the oxalic and uric, which generally emit a clear 
sound when struck with steel, and cannot be fractured without a con- 
siderable degree of force. Calculi, on the other hand, composed of 
ammoniaco-magnesian phosphate and phosphate of lime, are friable, and 
easily reduced to powder. In extracting such concretions from the 
bladder, they not unfrequently break under the pressure of the forceps. 
The cystic and fibrinous calculi are quite soft, the latter scarcely equal- 
ling that of yellow wax. It often happens that one part of a stone is 
hard and compact, while another is soft, friable, or even pulverulent. 
This diversity of consistence is strikingly exhibited in what are denomi- 
nated the alternating calculi, and seems to depend, in great measure, 
if not entirely, upon the component elements of the different layers of 
which such concretions consist. It is not improbable that the age of a 
stone may exert some influence upon its consistence, though it is impos- 
sible to estimate the amount or degree of it. 

" Stones are occasionally composed of a mixture of sabulous matter and 
hair, more or less intimately matted together. Their consistence re- 
sembles that of old lath-plaster ; they are easily crushed, or pulverized, 
and they are of whitish, grayish, or pale drab colour. Their formation 
is of rare occurrence, and they appear to consist principally of phos- 
phate of lime and magnesia. Where the hair comes from is not ascer- 
tained. 

" The colour of these bodies is not less variable than their other 
physical properties. The most common shades are white, grayish, drab, 
fawn, reddish, rose, and brown. Concretions of a bluish, greenish, 
black, or slate colour are rare. In the alternating calculi, a combina- 
tion of tints is generally observable, and even one part of the surface of 
a stone may differ essentially, in this respect, from another. The 
cystic and fibrinous calculi are of a yellow colour, not unlike that of 
yellow wax ; the phosphatic are whitish or grayish ; the oxalic, dark or 
blackish ; the uric, rose, reddish, or brown. 

1 London Medical and Physical Journal for 1828. 

2 London Medico-Chir. Trans., vol. xi. p. 82. 

3 Commer. Liter. Norirnb. 1739, hebd. 9. 



CALCULOUS DISORDERS. 529 

" Most calculi, at the moment of their extraction from the bladder, 
and for a short time afterwards, emit a strong urinous odour, which 
they gradually lose by exposure to the atmosphere. It may also be 
completely destroyed by ablution in warm water, and rapid desiccation 
before the fire. More or less, however, of the animal matter is usually 
retained, so that maceration, at any future time, if not too remote, is apt 
to be followed by a slight reproduction of the original odour. When 
sawed, rasped, or rubbed, urinary concretions give out a smell similar 
to that of bone, horn, or ivory. Fourcroy considered the spermaceti 
odour furnished by mulberry calculi, thus treated, as characteristic of 
the species ; this, however, is a mistake. 

" Vesical calculi are capable of assuming a great variety of forms*. 
The circumstances which are chiefly concerned in producing this result 
are the action of the bladder, the friction which the concretions, when 
multiple, exert upon one another, and the nature of the nucleus. One 
of the most constant symptoms of vesical calculus is a frequent mictu- 
rition, at the close of which the bladder always contracts violently upon 
the foreign body. When this contraction is uniform, the concretion 
will be likely to be of a regular figure ; but the reverse when this power 
is exerted unequally. The attrition which vesical calculi, when multiple, 
experience from the friction to which they are incessantly exposed, 
seldom fails to effect a change in their configuration. Such concretions 
are nearly always smooth, angular, and more or less polished, while, on 
the contrary, the solitary are generally rough, and comparatively 
regular in their shape. The influence exerted by the nucleus in moulding 
the form of the concretion is well illustrated by those cases in which 
the deposits take place round a foreign body, as a bullet, pin, needle, or 
bit of bougie, accidentally introduced into the bladder. The configura- 
tion of the stone, under such circumstances, almost always partakes of 
that of the extraneous substance. Finally, it is not unlikely that the 
chemical constitution exerts more or less influence upon the form of the 
concretion. 

" Vesical calculi are commonly of an oval form, but occasionally they 
are round, spherical, or even cylindrical. Other varieties of form are 
sometimes seen, as the conical, pyriform, cubic, triangular, pyramidal, 
gourd-like, polygonal, and the tetrahedral. Sometimes the concretion 
is thin and flat, like a coin, lenticular, semilunar, or in the shape of a 
mushroom, a kidney, a mulberry, a bean, or a heart. Again, it may 
be large and bulbous at the extremities, and narrow at the middle, like 
a dumb-bell. Dr. Mussey, Professor of Surgery in the Medical College 
of Ohio, has a most singular-shaped calculus, which he removed, many 
years ago, from the bladder of a man after death. It has a very delicate 
nucleus, from which a number of slender prongs project, of an irregu- 
larly cylindrical shape, and some of them upwards of an inch in length. 
A large concretion will occasionally assume the form of the bladder, 
and have even- prolongations or projections, representing the shape of 
the urethra, the ducts of the prostate gland, or the ureters. In fact, 
there is no end to the grotesque appearance of these foreign bodies. 
Morgagni speaks of a perforated stone, voided by a female. 

" The shape of a calculus is sometimes materially influenced by that 



51)0 CALCULOUS DISORDERS. 

of its nucleus. If this is very long, as when it consists of a piece of 
catheter, bougie, straw, or flower-stalk, the concretion will also be apt to 
be long and slender, the reverse being the case when the nucleus is 
rounded, or ovoidal. The fact is interesting in regard to the manner 
in which the foreign bod}'- should be seized with the forceps, with a view 
to its removal from the bladder, whether this be attempted by incision, 
or the natural channel. 

" The surface of these concretions may be smooth or rough. The 
former is generally the case when several exist together, from the fric- 
tion which they exert upon each other; when there is only one, how- 
ever, it is almost always rough. From the cause just mentioned, mul- 
tiple calculi may not only be smooth but even highly polished, and 
rendered angular, polygonal, rhomboiclal, or tetrahedral. The oxalic 
concretion derives its common name from the roughness of its surface, 
which resembles that of fruit of the mulberry. The uric acid calculus 
is usually finely tuberculated. In some of these foreign bodies the sur- 
face is scabrous, mammillated, knotty, convoluted, or covered with spines, 
prongs, or stalactites. 

" The chemical composition of urinary calculi has attracted much 
attention during the last fifty years, and the individuals who have parti- 
cularly distinguished themselves for their researches in this respect are 
Scheele, Bergmann, Wollaston, Brande, Marcet, Fourcroy, Prout, Ber- 
zelius, Henry, Scharling, Taylor, and Bird. In this country, the most 
valuable contribution that has been made to this branch of the chemical 
science is from the pen of Professor Peter, of Kentucky. His paper, 
which was originally published in the fifth volume of the Western 
Lancet, is founded upon an analysis of eighty-one calculi in the museum 
of the medical department of Transylvania University, and is one of 
deep interest in reference especially to the relative frequency of stone 
in Lexington, and the probable causes by which it is induced. To this 
paper, which has since appeared in a separate form, I beg leave to refer 
the attention of the reader for a large amount of valuable information, 
having a direct bearing upon the nature and composition of urinary 
concretions in a region of country where calculous affections are more 
common than in any other parts of America. It is to be hoped that 
the labours of Dr. Peter will have the effect of stimulating others to 
similar investigations ; for it is only by the combined researches of 
chemical philosophers in different portions of the country that the subject 
can be placed in its true light. 

" The subjoined account, which is transferred, with little alteration, 
from my work on Pathological Anatomy, includes the most important 
species of urinary concretions that have hitherto been described. 

" The uric calculus, called also the lithic calculus, the most common 
species of all, was first noticed by Scheele, in 1776. In its colour it is 
brownish, inclining to that of mahogany, of a flattened oval shape, occa- 
sionally finely tuberculated on the surface, but most generally smooth, 
though not polished, unless there are several concretions at the same 
time, and from the size of a currant to that of a hen's egg. If the uric 
calculus be divided with the saw, it will be found to consist of several 
layers arranged concentrically around a common nucleus, the laminae being 



CALCULOUS DISORDERS. 



531 



frequently distinguishable from each other by a slight difference in 
colour, and sometimes by the interposition of other ingredients. Water 
has but little action upon it ; it is perfectly dissolved by caustic potash ; 
and disappears with effervescence in hot nitric acid, the solution affording 
on evaporation to dryness, a bright carmine-coloured residue ; before 
the blow-pipe, it becomes black, emits a peculiar animal odour, and is 
gradually consumed, leaving a minute quantity of white, alkaline ashes. 
Fig. 179 shows the oval shape and finely tuberculated surface of the 
calculus ; Fig. 180 the internal concentric layers. 



Fig. 17' 



Fig. 180. 












" As a variety of the preceding the uro-ammoniac calculus may be 
here mentioned. It is principally observed in children, and is so ex- 
tremely rare that several distinguished chemists have been induced to 
deny its existence. It is generally of small size, with a smooth surface, 
of a clay colour, and composed of concentric rings, which present a very 
fine earthy appearance when fractured. Much more soluble in water 
than the uric calculus, it gives out a strong ammoniacal smell when 
heated with caustic potash, and deflagrates remarkably below the blow- 
pipe. This variety of calculous concretion was first described by Four- 
croy. 

" Next to the uric calculus, in point of frequency, is the oxalic, which 
is generally of a dark brown colour, and tuberculated on the surface, 
very hard, compact, and imperfectly laminated, seldom larger than a 
walnut, spherical, and always single. Under the blow-pipe, it expands 
and effloresces into a white powder ; it dissolves slowly in muriatic and 
nitric acid, provided it be previously well broken up. In the alkalies, 
it is perfectly insoluble. This species of urinary concretion, called by 
many the mulberry calculus, from its resemblance to the fruit of the 
mulberry, was first correctly analyzed, in 1797, by Dr. "YVollaston, who 
proved it to consist essentially of oxalate of lime. Figs. 181 and 182 
show the external appearance and internal structure of this concretion. 



532 



CALCULOUS DISORDERS. 
Fig. 181. Fig. 182. 






■ 




" A variety of this species of calculus has been described by 
Fig. 183. the term hemp-seed, from some resemblance which it bears in 
colour and lustre to that substance. Fig. 183. It is always 
of small size, remarkably smooth, and generally exists ir> consi- 
derable numbers, being rarely if ever found alone. 
" The phosphaiie calculus, Fig. 184, described by Wollaston in 
1797, is of a pale brownish colour, and of a loosely laminated structure, 
with a smooth, polished surface, like porcelain. The 
Fig. 184. shape is mostly oval, and the size, though generally 

small, is sometimes very considerable. It whitens 
when exposed to the blow-pipe, but does not fuse ; 
and readily dissolves in muriatic acid, without effer- 
vescence. This calculus, composed essentially of phosphate of lime, is 
extremely rare, as forming entire concretions, but frequently consti- 
tutes alternate layers with other matters. It is sometimes called the 
bone-earth calculus, aud occasionally contains small quantities of carbo- 
nate of lime. 

" The next species is the ammoniaco-magnesian, so called from its being 
composed of the phosphate of ammonia and mag- 
nesia. Fig. 185. This mixed calculus is of a 
white colour, friable, crystallized on the surface, 
and looks a good deal like a mass of chalk : its 
texture being never laminated, it easily dissolves 
in dilute acids, but is insoluble in caustic potash ; 
before the blow-pipe, it exhales an ammoniacal 
odour, and at length melts into a vitreous sub- 
stance. This species of concretion, first noticed 
by Wollaston in 1797, sometimes attains an immense size. In a case 
mentioned by Dr. Thompson, the circumference was fourteen inches, 
and the weight nearly two pounds. 

" The fusible calculus, the nature of which was first determined by 
Wollaston, consists of a combination of the last two. It is of a white 
colour, extremely brittle, leaves a soft dust on the fingers, and is 
easily separated into layers ; when broken, it presents a ragged, uneven 
surface. It is insoluble in caustic potash, but gives off ammonia ; and, 
under the blow-pipe, it is readily converted into a transparent, pearly- 



Fig. 185. 




WHP 



CALCULOUS DISORDERS. 



533 



looking glass. This concretion is very common, and sometimes attains 
a very large size. It is frequently met with as an incrustation of 
foreign bodies. Figs. 186 and 187 exhibit the outer appearance and 
internal structure of this concretion. 



Fig. 186. 



Fiff. 187 




w 



W 




" A very rare species of urinary concretion is the Cystic, so called 
from an erroneous supposition that it was peculiar to the bladder. It 
consists of a confused, crystallized mass, of a white yellowish colour, 
with smooth surface. The structure is compact, and the fracture 
exhibits a peculiar glistening lustre, like that of a body having a high 
refractive density. It exhales a strong characteristic odour under the 
blow-pipe, and is very abundantly dissolved in acids and alkalies, with 
both of which it crystallizes. This species is commonly of an irregular 
spherical shape, and seldom attains a large volume. Wollaston termed 
it an oxide, and gave it the name of cystic, from a belief that it occurred 
exclusively in the urinary bladder. It has since been detected, however, 
in the kidney. The external and internal appearances of the cystic 
calculus, are shown in Figs. 188 and 189. 



Fig. 188. 






Fig. 189. 




" The xanthic calculus was first pointed out by Dr. Marcet, whose 
account of it is the best that is extant. It is extremely rare. Its 



534 CALCULOUS DISORDERS. 

texture is compact, hard, and laminated : its colour is of a cinnamon 
brown, its surface smooth, and its volume small. It dissolves very 
readily in acids and alkalies, and is gradually consumed before the 
blow-pipe, leaving a minute quantity of white ashes. 

" There is what is called the fibrinous calculus. Like the preceding 
species, this is also extremely rare, and appears to be composed princi- 
pally of the fibrin of the blood, a property to which it owes its name, 
and by which it is characterized. Sir Benjamin Brodie 1 has described 
a concretion of this- kind, which was about the size of a horse-bean, of 
an oval shape, and of a yellow transparent appearance, not unlike amber, 
but less hard. When dried, it shrunk to a small size, and became con- 
siderably shrivelled. 

" Finally, there is a concretion recently described by Heller, under 
the name of urostealith. It is exceedingly rare, and I do not know that 
anybody else has noticed it. The specimen, analyzed by the German 
chemist, was obtained from a man of tolerably good constitution, 
twenty-four years of age, whose chief complaint was pain in the region of 
the right kidney, with difficulty in micturition. The concretions were 
of a rounded form, soft, elastic, and from the volume of a hemp-seed to 
that of a hazel-nut, most of them being as large as a pea. They become 
brittle on being dried, when they present the appearance of wax, of a 
greenish-yellow hue when viewed by transmitted light. When heated, 
they melt, and emit a peculiar pungent odour, similar to that of benzoin. 
Urostealith is readily dissolved by ether and by solutions of caustic 
potash, but it is insoluble in boiling water, and nearly so in alcohol. 
It seems to be composed of a particular kind of fatty matter." 2 — (Dr. 
Gross, on Diseases and Injuries of the Bladder, p. 347-359.) — Ed.] 

SYMPTOMS OP CALCULUS IN THE BLADDER. 

The leading symptoms produced by a calculus in the bladder are, a 
frequent, sudden, and urgent desire to pass water, the desire being often 
irresistible, especially under exercise, or on change of position, — and 
pain referred to the point of the penis, most severe, just as the bladder 
is emptied, and after making water, when the contraction of the middle 
coat brings the mucous coat into distinct contact with the calculus. The 
pain is sometimes of a burning character ; at other times, it is a severe, 
but dull pain, with a sensation as of something lodged at the part, and 
giving rise to a desire to pull and pinch the prepuce, causing it to be- 
come elongated. The skin of the fore-finger and thumb, especially in 
children, in whom the inclination to pull the prepuce is often observed, 
becomes, in consequence of being kept wet by the urine, sodden and 
white like that of a washerwoman's hands. Sometimes the flow of the 
urine is suddenly stopped by the stone covering the inner orifice of the 
urethra, and is restored on a change of posture removing the stone from 
that position. As the stone increases in size, the symptoms become 
more and more urgent ; the pain at the point of the penis is frequently 
accompanied by sympathetic pain about the rectum similar to tenesmus ; 
and in most instances, after the disease has been of long standing, the 

•Lectures on the Urinary Organs, p. 214, second edition. London, 1835. 
2 Simon's Animal Chemistry, p. 635, Phila. 1846 ; also Markwick on Urine, p. 93, 
Phila. 1848. 



CALCULOUS DISORDERS. 535 

urine ceases to be so clear and transparent as natural, and deposits on 
cooling, especially after exercise, a quantity of mucus. 

Such are the leading symptoms caused by a stone of moderate size ; 
but, in the course of time, these symptoms become painfully aggravated, 
other local symptoms supervene, and the general health, at first little 
affected, becomes impaired, so that the patient's situation is rendered 
peculiarly distressing. The urine, instead of preserving its natural 
clear and transparent appearance, becomes at first merely opalescent 
from the mucus thrown off by the lining membrane ; which mucus is 
seen, as the urine cools, to subside to the bottom of the recipient vessel, 
and in some cases, is at times tinged with blood. As the disease ad- 
vances, the congestion of the lining membrane goes on to inflammation, 
in which state its sensibility is greatly increased, the desire to make 
water is almost constant, the pain most excruciating, the urine offensive, 
and loaded with mucus, tinged with blood, its smell foetid and ammo- 
niacal, and by and by, it contains purulent matter along with the mu- 
cus. Inflammation of the mucous membrane aggravates all the symp- 
toms to a very great degree ; the pain at the point of the penis is 
excruciating and attended with the inclination to squeeze the glans 
penis, — the agony being no doubt caused by the inflamed bladder spas- 
modically grasping the stone. The sympathetic pains are often very 
distressing, and are felt shooting down the thighs, and in the soles of the 
feet. The rectum is not only affected by such pains, but it also becomes 
irritable, and often liable to prolapsus ani, or to hemorrhoids. 

The above are the leading and diagnostic symptoms of stone in the 
bladder ; but as some of them are somewhat similar to the symptoms of 
other affections, such as disease of the bladder, disease of the prostate 
gland, organic disease of the kidney, renal calculus, and (to some ex- 
tent) organic disease of the rectum, the surgeon should, before giving a 
positive opinion, make use of the sound, and when, by means of this 
instrument, he feels the calculus, he is as fully convinced of its existence 
as if he actually saw it. 

VARIETIES AS TO THE DEGREE OF PAIN IN DIFFERENT PERSONS, AND IN 
THE SAME PERSON AT DIFFERENT TIMES. 

The degree of pain produced by a vesical calculus varies much in dif- 
ferent cases, and even in the same person at different times, and in 
different stages of the affection. The varieties in different persons de- 
pend chiefly on the size and figure of the stone, on its smoothness or 
roughness, on the nature of the stone, the quality of the urine, and, 
when other things are equal, on the condition of the bladder. A small 
stone occasions less pain than a large one, and one that is smooth on 
the surface less than one that is rough, the rough nodules irritating the 
mucous membrane ; and this is the reason why the mulberry calculus in 
most instances causes so great pain. But of all the calculi none are so 
painful as the phosphatic, which is no doubt owing to the greater degree 
of derangement of the general health, and to the general and local sus- 
ceptibility being morbidly increased. An unusually acid or alkaline 
condition of the urine will increase the sufferings of the patient, the 
fluid being in each case too stimulating for the lining membrane ; but 
the greatest pain is experienced in an inflamed condition of the bladder, 



536 



CALCULOUS DISORDERS. 



Fig. 190. 



as the sensibility of the bladder is thereby greatly increased. The 
diathesis itself sometimes varies in the same person, and there is then 
a corresponding variation in the roughness or smoothness of the surface 
of the stone — changes which, apart from some of the facts stated above, 
sufficiently explain why the sufferings of the patient are so much greater 
at some stages of the concretion than at others. 

SOUNDING. 1 

Although a patient may have many or all of the rational signs of 
stone, nothing can positively convince the surgeon of its presence but 
feeling it with the sound. 

A sound is an instrument made of polished steel, shaped somewhat 
like a catheter. The handle should be smooth, so as 
to communicate the most delicate impression to the 
fingers, and the point should be rounded, so as not to 
be arrested in the orifices of the prostatic or seminal 
ducts. The curve near the point should neither be 
too long, too acute, nor too obtuse, in order to facili- 
tate the movements of the instrument when introduced 
into the bladder, and to bring it more accurately in 
contact with the stone. 

Previously to sounding, the bowels should be emptied 
by a dose of castor oil or an enema. A full rectum 
may impede the movements of the instrument, and 
impart deceptive sensations to the hand of the sur- 
geon. 

A patient is never sounded with an empty bladder. 
The patient should be directed to retain his urine, but 
should he have inadvertently passed it, the bladder is 
to be distended with three or four ounces of tepid 
water, injected through a silver catheter, which may 
then be used as a sound, care being taken to stop its 
orifice, to prevent the regurgitation *>f the fluid. 

During the operation of sounding, the patient should 
be on his back, near the edge of the bed, with his 
shoulders elevated, and his limbs flexed, so as to relax the abdominal 

Fig. 191. 





muscles. The instrument is introduced in the same manner as a cathe- 
1 Condensed from Dr. Gross' work on Urinary Organs. 



CALCULOUS DISORDERS. 537 

ter, and if the stone is not felt at once the sound must be rotated upon 
its axis, so as to explore every portion of the bladder. Sometimes the 
stone cannot be felt on account of its lying in a pouch in the bas-fond 
of the bladder, just behind the prostate gland. When this is the case 
the finger should be oiled, and introduced into the rectum, and the stone 
pushed upwards against the sound. It may be necessary to change the 
position of the patient, making him lie on his side, sit or stand, bend 
forward, or raise his buttocks. The stone may be contained in the folds 
of the bladder, or some abnormal pouch ; or it may be adherent to the 
walls of the bladder. Small stones have been found imbedded in the 
parietes of the bladder. Several such calculi are represented in the ac- 
companying figure. 

The calculous matter, instead of being collected into a distinct concre- 
tion is sometimes spread out in the form of a layer upon the bas-fond of 
the bladder. The crust varies in thickness, and is sometimes difficult 
to break. It grates under the sound, and when struck emits a peculiar 
noise, not unlike that of a cracked pot. But the noise produced by 
striking a free calculus is a click, or a clear metallic resonance, which is 
more distinct when the stone is hard. The sense of touch is also readily 
impressed by the contact of the stone, and through it the volume of the 
calculus can be in some measure ascertained. There is danger in sound- 
ing patients who have travelled a great distance for surgical relief, be- 
fore they have recovered from the fatigue. Cystitis and peritonitis 
may result to such an extent as to endanger the life of the patient. 

The sounding should always be conducted with the utmost gentleness, 
and should never be continued beyond a few minutes at a time. A pro- 
tracted operation of this kind is generally productive of mischief, and 
cannot be too pointedly condemned. Should severe pain ensue, it must 
be allayed by a full anodyne ; and any inflammatory symptoms that 
may arise are to be combatted by the usual remedies. In all cases the 
patient should be directed to make free use of demulcent drinks. 

" Although sounding is the only certain method of detecting a stone 
in the bladder, it is occasionally liable to error. Numerous cases are 
upon record where a foreign body was supposed to be present, and 
where the poor patients were subjected to all the pains and perils 
of lithotomy, and yet no calculus was found, either at the time of 
the operation or after death. Surgeons of the most consummate skill 
and the most extensive experience have fallen into this error. It 
is for the purpose of avoiding a repetition of such mistakes, so discre- 
ditable to those who commit them, that I shall endeavour briefly to 
point out their sources. Great men may sometimes commit an error 
with impunity which would bring ruin and disgrace upon a more humble 
member of the profession. Cheselden, 1 the most celebrated lithotomist 
of his age and country, cut three patients without finding any stone. 
Blanc, 2 Dupuytren, 3 Roux, 4 and Crosse, 5 all operated, expecting to find 

•Benjamin Bell's System of Surgery, ii. p. 40. Edinburgh, 1784. 

2 Dessault's Chirurgical Journal, translated by Gosling, i. p. 125. London, 1794. 
3 Lecons Orales, T. ii. p. 334. 

4 Johnson's Medico-Chir. Rev., April, 1827, p. 549. 

3 Essay on Urinary Calculus, p. 50. 



538 CALCULOUS DISORDERS. 

a stone, where there proved to be none. The late Dr 
very near committing the same mistake. He sounded a patient, and had 
no doubt there was a stone. His health, however, was bad, and the 
operation was postponed. He died some time after, and upon exami- 
nation no stone was found. 

" Mr. Crosse, 2 who, as we have just seen, was himself unfortunate in 
one instance, states that he has notes of not less than eight cases in 
which the operation was needlessly performed, and to several of which 
he was an eye-witness. The late Mr. Samuel Cooper, 3 of London, was 
acquainted with the particulars of at least seven such cases, at two of 
which he was present. Velpeau 4 says he has a knowledge of four in- 
stances, where the patients were subjected to the operation without 
there being any calculi in the bladder. South 5 mentions the case of a 
child, two years and a half old, who was cut for stone, but in whom no 
stone was found, although he had suffered very severely, and a calculus 
was supposed to have been felt. I am acquainted with two instances 
in which the patients were lithotomized without there being any stone. 
One of these was a child, under four years of age, whose parents resided 
in Indiana. He was sounded several times, and a stone was supposed 
to be present, but none was found at the time of the operation. He 
recovered quickly, and is still living. The other case occurred in Ken- 
tucky, in an old man, upwards of sixty years of age, who was cut by 
the same surgeon, under the supposition that he had calculus. He died 
a few days after the operation, and, upon examination, the bladder was 
found to contain nothing but a fungous tumour, portions of which had 
repeatedly come away by the urethra during life. Many similar ex- 
amples are recorded in the ' Memoires de l'Academie de Chirurgie' of 
Paris. It is worthy of remark, that quite a number of the patients in 
whom no stone was found were promptly and entirely relieved of the 
symptoms which had been attributed to its presence. On the other 
hand it is equally certain that some of them perished from the effects of 
the operation, while others who survived it received no benefit from it. 

" The circumstances which may lead to the commission of the error 
above mentioned differ very much in their character, and are dependent 
for their origin either upon the bladder itself, or upon the surrounding 
parts. The following are the most important. 

"I. In the first class are included an indurated and contracted state 
of the bladder, the development of an osseous cyst, and the formation of 
a fibrous, encephaloid, or polypus tumour, and a deposit of tubercular 
matter. 

" II. In the second division of the subject may be comprised certain 
affections which involve the parts in the immediate vicinity of the 
bladder, as the prostate gland, rectum, uterus, vagina, and pelvic 
bones." 6 — Ed.] 

Treatment. — Of the various modes of treatment recommended for the 

1 Liston's Practical Surgery, by Norris, p. 310. Philad., 1838. 

2 Essay on Urinary Calculus, p. 50. 

3 Dictionary of Surgery, vol. ii. p. 134. New York, 1842. 

4 Velpeau, Operative Medicine, vol. iii. p. 891. 

5 Chelius's Surgery, South's Edition, vol. iii. p. 277. 

6 Dr. Gross, on Diseases and Injuries of the Bladder, p. 3S0-384. 



LIT K OTOMY. 



539 



removal of calculus, we shall refer to three, Lithotomy, Lithotrity, and 
Lithotripsy. 

LITHOTOMY, OR CUTTING FOR THE STONE. 

In the next section, which gives the history of Lithotomy, will be 
found the various modes in which the operation has been performed. Of 
these (several of which are not now in the list of regular and established 
operations), that which is to be preferred in almost every instance in 

Figs. 192-195. 




which lithotomy is justifiable, is the lateral 
operation. The several acts of this operation are 
variously performed ; but the method of the late 
lamented Mr. Liston, who, while he lived, was 
deservedly regarded as the first lithotomist, has 
brought it to a state of the greatest simplicity 
and elegance, and has been adopted by the 
great majority of operating surgeons. 

The perinseum having been shaved, the rec- 
tum having been cleared by a dose of castor oil 
on the evening before, and an injection on the 
morning of the operation, — the patient, having 
retained his urine from half an hour to three 
quarters of an hour previous to the operation, 

should be brought under the influence of chloroform, and then a staff of 
the largest size the urethra will admit, having a deep groove between 
its convexity and left side, should be introduced, and the stone having 
been felt, the charge of the staff should be given to the principal assis- 
tant. The hands and feet of the patient should be tied to each other, 




540 



LITHOTOMY. 



and his body placed in the attitude shown by the accompanying drawing. 
If the staff be of the largest size that can be conveniently introduced, 

Fig. 196". 




it will be easily felt after the first incision, and the urethra can without 
difficulty be opened upon it. The staff should be drawn up under the 
pubes to keep the prostate gland from being imbedded in the rectum, 
and held steadily by the assistant in that position throughout the diffe- 




rent stages of the operation. The operator should then introduce the 
fore-finger of the left hand into the rectum to make sure of its being 



LITHOTOMY. 



541 



empty, and to excite it to contract, which will diminish the risk of its 
being injured during the operation. I have always followed the example 
of Mr. Liston in making the introduction of the finger into the rectum 
the last thing before the commencement of the operation, in order to 
diminish the danger of its being wounded, and the first thing after its 
completion, to make sure of its being safe. The first incision is then 
made by introducing the knife pretty deeply into the perineum at the 
left side of the raphe, and about an inch in front of the verge of the 
anus, and by carrying it downwards and outwards to rather more than 
an inch below the anus, and so directing it that the middle of the incision 
may be about midway between the anus and the tuberosity of the ischium. 
By this means the skin and superficial fascia are divided. The fore- 
finger of the left hand is then pressed into the middle of the wound for 
the purposes of putting aside cellular tissue and thereby enlarging the 
wound, of keeping the rectum out of harm's way, and of feeling for the 
staff in the membranous portion of the urethra. Such fibres of the 
transversus perinei and levator ani muscles as oppose the onward 
progress of the finger should be carefully divided by the knife. The 
groove of the staff is easily felt anterior to the deep fascia of the peri- 
neum. The point of the nail of the fore-finger should be pressed against 
the groove, and the knife, carried along the back of the finger, should 
be made to enter the groove about three lines in front of the prostate ; 
and it having been surely ascertained that the knife is in the groove of 

Fie. 198. 




the staff, it should^be cautiously pressed backwards so as to divide that 
portion of the membranous part of the urethra which is posterior to 
where the knife enters the groove, the deep fascia and fibres contained 
within it, the prostatic portion of the urethra, the left lobe of the pros- 
tate gland, and the dense unyielding fibrous band at the base of the 
prostate, into which the muscular fibres are inserted. The incision 
should commence about three lines in front of the gland, and should not 
extend beyond its circumference, so that there may be no risk of the 



542 



LITHOTOM Y. 



ilio-vesical fascia being divided,, as such division- would admit of infiltra- 
tion .by breaking up the barrier which this fascia constitutes between the 
external and internal cellular tissues. The edge of the knife should be 
directed downwards and outwards. If it be held too horizontally, the 
section of the prostate, so made as not to extend beyond its base, would 
be too limited, and the planes of the external and internal incisions 
would not correspond : if too vertically, the section obtained would also 
be too limited, and the rectum would be endangered. The finger should 
be so placed as to protect the rectum, and should follow the knife, which 
is withdrawn as soon as the incision has been made, and immediately 
afterwards the principal assistant withdraws the staff, the surgeon re- 
Fig. 199. 




taining his finger in the section of the prostate. In most instances the 
stone can be felt with the front of the finger ; the forceps should then 
be introduced, the finger being used as a guide. When the forceps 
reaches the stone, its blades should be opened, the stone seized, and 
efforts made to extract it, the handles of the forceps being depressed so 
that the line of extraction may be in the direction of the axis of the 
pelvis, and the fore-finger of the left hand preventing the descent of the 
bladder with the stone and forceps. To make the external incision free, 
facilitates the remaining steps of the operation : but the internal incision 
should be limited; — the great object being to avoid cutting beyond the 
circumference of the prostate, so that the ilio-vesical fascia, which 
is the barrier between the external and internal cellular tissues, may be 



LITHOTOM Y. 



543 



Fig. 200. 



entire. The prostate, the mucous coat and muscular fibres at the neck 
of the bladder are so yielding that the wound can be easily dilated 
without any laceration, and thus a stone of very considerable size can 
be readily extracted through an incision of very limited extent, perhaps 
not more than seven or eight lines in length, and not ex- 
tending into the bladder beyond the base of the prostate. 
If the stone should be too large to be safely extracted through 
the limited opening now described, the most judicious course 
then is to introduce a probe-pointed bistoury along the 
finger, and effect a similar incision on the right side of the 
prostate ; in short, to make what is called the bilateral sec- 
tion of the gland — a proceeding which may be adopted from 
the first, if it is certain that the stone is too large to be ex- 
tracted through a section on one side of the prostate gland. 

It having been ascertained by the appearance of the 
stone, or, if necessary, by the use of the searcher, that 
there is not another calculus, the elastic tube is introduced 
into the wound to facilitate the escape of the urine, and 
thereby to diminish the danger of infiltration ; and for the 
promotion of the same object, .the patient after being re- 
moved to bed, is placed on his back with his shoulders a 
little raised. Such is the simple and safe mode of per- 
forming lithotomy with the knife, recommended by Mr. 
Liston, and which I often witnessed with the greatest admi- 
ration when I was his pupil. 

[Many operators prefer a probe-pointed knife. Dr. Gross 
employs a probe-pointed bistoury closely resembling that of 
Blizard.— Ed.] 

The structures divided in this operation are the integu- 
ment, two sets of fasciae, namely, the superficial fascia and 
the two layers of the deep fascia ; the transverse muscle of 
the perineum on the left side, some of the fibres of the leva- 
tor ani, and the muscular fibres between the two layers of 
the deep fascia ; the external hemorrhoidal arteries, and 
the transverse artery with their associate veins and nerves ; 
the cellular and adipose tissue in the ischio-rectal excava- 
tion ; a few lines of the back part of the membranous portion of the urethra, 
the prostatic portion of the urethra, the left lobe of the prostate gland, 
and the dense, unyielding, fibrous band at the base of the prostate, into 
which the muscular fibres are inserted. If the incisions are properly 
arranged, the above are the only structures that will be interfered with. 
The principal dangers to be guarded against are, bruising the soft parts, 
wounding the rectum, wounding some important artery, as the artery of 
the bulb, and too extensive division in making the section of the pro- 
state. The precautions to be adopted for avoiding the first and second 
of these dangers have been mentioned ; the third is avoided by not com- 
mencing the incision too high up : and the fourth by limiting the extent 
of the incision so as not to cut the bladder beyond the circumference of 
the prostate. Some arteries occasionally deviate from their usual 
arrangement, and are then in danger of being wounded. The artery of 



544 



LITHOTOMY. 



the bulb occasionally arises from the pudic near the tuber ischii, and 
crosses the line of incision. Should it be wounded, it ought if possible to 

Fig. 201. 




■■WMi||[iiM1l 



wm^ wmm 



-ijiiMk; 



be secured by a ligature. The pudic artery, even when presenting that 
abnormal arrangement in which it lies on the posterior edge of the pro- 
state, would be wounded only if the incision reached beyond the gland ; 
— an additional reason to that already given for limiting the extent of 
the section. In old persons there is sometimes venous hemorrhage 
from the veins around the prostate, which often become enlarged at an 
advanced period of life. This is most efficiently arrested by pressing 
some plugs of lint around the tube ; and the same plan is adopted in 
the case of arterial hemorrhage, when it is difficult to find the artery, 
and the hemorrhage does not cease on the thighs being brought toge- 
ther, which, however, it often does from the opposite sides of the wound 
being then more closely pressed against each other. In the event of 
lint being introduced, it is necessary to be even more than usually careful 
that the tube be kept completely pervious. 

The principal object of the tube being to prevent urinary infiltration, 
it is retained until it is reasonable to suppose that the cells of the cel- 
lular tissue are closed by effusion of lymph. In young persons, twenty- 
four hours will be sufficient for this purpose, the process of effusion being 
rapid at that period of life ; but in persons of a more advanced age, or 
of a relaxed habit of body, it should be retained for at least forty-eight 
or fifty hours ; and the greatest care taken for the first few hours after 
the operation until the urine become colourless, to observe that occlusion 
of the tube be not produced by coagulated blood. The important objects 

[Fig. 201. This engraving, copied from Scarpa, represents the left lobe of the prostate 
as it is divided in the lateral operation, a, Marks the incision of the membranous portion 
of the urethra and the side of the gland, b. The left lobe of the prostate, b*. The right 
lobe of the organ, c. The bulb of the urethra. Close behind are observed Cowper's 
glands, d, d. The legs of the penis, e, e. The seminal vesicles. //. The deferent ducts. 
g. The ureter of the left side. — Ed ] 



HISTORY OF PERINEAL LITHOTOMY. 545 

of attention for the first few hours are, that there be no hemorrhage, 
that the tube be pervious, and that the urine flow plentifully, and gra- 
dually become colourless. The secretion having become colourless, and 
no particular constitutional sympathy having manifested itself, the early 
and principal dangers are passed. On the withdrawal of the tube, the 
wound may be dressed with a little lint, and subsequently with a little 
lint dipped in oil, resinous ointment or turpentine liniment, according 
to the particular state of the granulations. In many instances no appli- 
cation whatever is required. The greatest care should be taken to keep 
the nates free from inflammation and excoriation by the use of the spirit 
lotion, lard, and the frequent change of sheets, so as to keep the parts 
as dry as possible ; the mind should be encouraged, the strength kept 
up by all means which in the particular circumstances of the case would 
be judicious, the frequent error of keeping the patient too low avoided, 
and the constitutional treatment in other respects conducted according 
to the common principles of surgery. In the course of eight or ten days 
a little urine comes by the urethra, generally causing a slight pain and 
irritation the first time, and the patient seldom' feels so well for that 
day ; the quantity gradually increases, and in three or four weeks, 
sometimes more and sometimes less, the whole comes by the urethra, 
and the continuity of the parts is restored by the healing of the wound 
after which the treatment proper for the diathesis should be continued, 
as reproduction of stone occasionally though very rarely occurs. 

[With regard to the result of the operation, Dr. Gross states, " It has 
been calculated that about one patient out of every five that are cut for 
stone by the lateral method perishes : and this estimate, taking the 
general average results, is, perhaps, pretty near the truth. Considered, 
however, with reference to individual operators, it is incorrect. Thus, 
taking the results furnished by some of our own lithotomists, it will be 
found that they afford a much more gratifying picture. Dr. Dudley, 
for instance, is said to have lost only 5 cases out of 180 cut, up to the 
beginning of 1846 ; Dr. Mettauer, of Virginia, 2 out of 73; Dr. John 
C. Warren of Boston, 2 out of 30, of which three, however, were by the 
bilateral method ; and Dr. Gibson of Philadelphia, 6 out of upwards of 
50. My own cases, amounting to 24, have all been successful. I in- 
variably use the knife ; while Dudley and Gibson employ the gorget. In 
the Pennsylvania Hospital, at Philadelphia, between 1752 and 1848, 
83 cases of stone were cut by the lateral method, and except in a few 
instances of very young children, by means of the gorget. Of this num- 
ber 72 were cured, and 10 died; 1 being set down as relieved." 1 — Ed. 

HISTORICAL SKETCH OF PERINEAL LITHOTOMY. AND THE VARIOUS MODES 

OF OPERATING. 

THE METHOD OF CELSUS. 

This mode of operation, the most ancient on record, and the only one 
in use down to the sixteenth century, deriving its name of Lithotomia 
Celsiana from having been described by Celsus, has also been called 

1 Dr. Norris's Report on Surgery, Trans. Amer. Med. Assoc, vol. i. p. 163. 

85 



546 HISTORY OF PERINEAL LITHOTOMY. 

cutting on the gripe, and, the operation by the apparatus minor, on 
account of the fewness of the instruments required, — a knife and a hook, 
and sometimes only a knife having been used. 

The rectum having been emptied by means of a clyster, and the patient 
having walked about the room to bring the stone down to the neck of 
the bladder, he was placed in the lap of an assistant, whose duty it was 
to hold him, and to keep the thigh bent and separated so as to expose 
the perineum. Sometimes, if the patient was not a young person, two 
assistants were strapped together by the thighs to support him between 
them, each having charge of a thigh. The operator, having oiled his 
fingers, introduced the index and middle fingers of the left hand into 
the rectum, and endeavoured to get them behind the stone, to force it 
forwards to the neck of the bladder, and to make it cause a prominence 
in the perineum. A lunated incision was then made, having its con- 
vexity forwards to the bulb of the urethra and its concavity backwards 
to the anus, the extremities being directed to the ischia. The words 
of Celsus, " cornibus ad ischia spectantibus," show that those writers 
are mistaken who say that the extremities of the incision were directed 
to the left hip. The parts between the middle of this incision and the 
stone were cut through, and the operator then endeavoured to press the 
stone through the wound, or to extract it by means of a hook. 

THE OPERATION BY THE APPARATUS MAJOR. 

The next operation we read of in the history of perineal lithotomy is 
known by the names of the operation of Johannes Romanus, by whom 
it was devised, — the Marian operation or the Sectio Mariana, in con- 
sequence of a minute description of it having been given by Marianus 
Sanctus, a pupil of Johannes Romanus, — the operation by the apparatus 
major, from the multiplicity of instruments employed (1' operation par 
le grand appareil, Fr.), and median lithotomy, from the first incision 
having been made in the mesial line in the perineum. . The reason 
assigned for the introduction of this mode, and the abandonment of that 
previously in use, was the declaration of Hippocrates that "wounds 
of membranous parts are mortal." It was supposed, however, that such 
parts might be dilated with safety, and it was on the principle of dilata- 
tion that the operation was founded. The patient having been placed 
on a table with his shoulders raised, his hands were bound to his feet, 
and the latter were separated from each other, drawn upwards, and still 
more firmly fixed by turns of a bandage passed round his neck and 
shoulders ; and in this attitude he was held by assistants. A grooved 
staff was then introduced into the bladder, and an incision made with a 
razor in the middle line of the perineum extending from behind the 
scrotum to near the verge of the anus ; by the further application of the 
knife the bulbous portion of the urethra was opened ; and this was all 
the cutting employed in the operation. The operator having the point 
of the knife lodged in the groove of the staff, introduced a probe into 
the bladder, guiding it by the knife into the groove, and by the staff 
into the bladder. The knife and staff having been withdrawn, the in- 
struments for dilatation were then used. These were two, called the 
male and female conductors. The female conductor, which was a long 
director with a groove, was introduced along the probe, when the latter 



HISTORY OF PERINEAL LITHOTOMY. 



547 



was withdrawn, and the point of the male conductor having been placed 
in the groove of the female, was pressed onward into the bladder. The 
lithotomist then, by taking the extremity of a conductor into each hand, 

Figs. 202— 207. 




and separating them from each other, commenced the work of dilating,. 
or rather tearing up the membranous and prostatic portions of the 
urethra and the neck of the bladder. After all the dilatation that could 
be effected by the conductors had been accomplished, the grand forceps 
was introduced between them into the bladder, and employed first in 
still increasing the dilatation, and then in seizing and extracting the 
stone. After Marianus, who gave the first description of the operation, 
his successors contrived many other instruments to be used after the male 

Figs. 202 — '207. " Insti-uments constituting the "Apparatus Major." 



548 HISTORY OF PERINEAL LITHOTOMY. 

and female conductors, in tearing open the neck of the bladder. The 
principal of these were the gorget of those days, which was in use in the 
time of Collot, though its employment was not patronised by him ; the 
simple dilator, which dilated by its handles being brought together ; the 
dilator of some authors, an entirely different instrument ; and the double 
dilator. By some or other, or all of the above-mentioned instruments, 
together with the fingers of the operator, the membranous and prostate 
portions of the urethra, prostate gland, and neck of the bladder, were 
torn open to make room for the extraction of the stone. The cruelties 
of this operation could scarcely have been exceeded ; but although its 
results were such as might have been expected, it was still practised 
from 1520, when it was first proposed, to 1697, when Frere Jacques de 
Beaulieu taught the surgeons of Paris to despise it, and proposed another 
mode of operation. 

Some of the most celebrated operators with the grand appareil, were 
Marianus, Paraeus, the family of the Collots, who were Lithotomists to 
the kings of France for several generations (the elder Collot having 
been appointed Royal Lithotomist to Henry II., and having been the 
first person on whom that title was conferred), Octavius de Ville, Toletus, 
and Mery and Marechal, the surgeons-in-chief to the Hotel Dieu and 
La Charite Hospitals in Paris. 

OPERATION OF FRERE JACQUES. 

Frere Jacques, a native of Langsauniere, in Burgundy, devised a 
method of cutting for the stone, which shall presently be described. 
Having practised this method with success in various towns on the Con- 
tinent, he went to Paris, where he had influence enough to obtain from 
President Harley an order to perform his operation on a dead body in 
the Hotel Dieu in the presence of the surgeons of Paris. Mery, sur- 
geon-in-chief of the hospital, was required to report regarding it. 

On the 7th of December, 1697, Mery received the first order to wit- 
ness Frere Jacques cut a dead body for the stone in the Hotel Dieu, and 
on this experiment he gave a most favourable report. On the 14th of 
the same month he received a second order from the president to witness 
Frere Jacques make further trials of his operation on dead bodies in the 
Hotel Dieu ; and it is remarkable that Mery, who indeed is supposed 
to have been influenced by the violent jealousies entertained towards 
Frere Jacques by the lithotomists and surgeons of the day, and to have 
become the organ of their party, reported in opposite terms of these 
further experiments, and condemned what previously he had strongly 
praised. In consequence of this, Frere Jacques lost the support of 
President Harley, and being dispirited, left Paris without being allowed 
to perform his operation on the living body. He went to Fontainebleau, 
where he was introduced to Daschene, one of the physicians to the court; 
to Bourdelot, physician to the Duchess of Burgundy ; to Fagon, phy- 
sician, and to Felix, surgeon to Louis XIV. : and by the influence of 
these gentlemen an order was given by the court, that he should per- 
form his operation on a boy from Versailles, then living at Fontaine- 
bleau, who was afflicted with the stone. He performed the operation 
in the presence of the above-named gentlemen, and in a manner to com- 



HISTORY OF PERINEAL LITHOTOMY. 549 

mand their admiration, and in three weeks the boy was seen running in 
the streets perfectly well. The consequences were, that Frere Jacques 
cut six other persons at Fontainebleau, gained the favour of the court, and 
the enthusiasm of the people, and returning to Paris, and there operating 
in private on twelve persons, produced such an impression on the public 
mind, that President Harley summoned a meeting of the physicians, 
surgeons, and managers of the Hotel Dieu, together with the magistrates 
of Paris, and others, at the palace of the archbishop, on the 7th of 
April, 1698, requiring another report on this operation. The contest 
at this meeting is said to have been very violent. The operators by 
the apparatus major finding that all they had been proud of in their 
method was in danger, with themselves, of falling into neglect, were as 
strong in their opposition to the new mode as the friends of Frere 
Jacques were in their approval of it ; but the final result of the discus- 
sion was, that the latter were triumphant, and it was resolved that, in 
the ensuing season of cutting for the stone, Frere Jacques should be 
allowed to perform his operation in the Hotel Dieu and at La Charite'. 
He operated accordingly, but unfortunately for him, of sixty-two patients 
whom he cut in those hospitals, twenty-five died, seven having been 
carried dead out of La Charite' in one day. This occasioned the renewal 
of the persecution which had before been directed against him, and it 
was now carried on not only by the lithotomists and surgeons, but also by 
the priests, whose violent hatred he had incurred by accusing them of 
having poisoned his patients and injured their wounds for the purpose of 
bringing discredit on his operation. A second time therefore he left 
Paris, but continued to practise his operation in the chief towns of France, 
in Holland, and in Germany, to the great admiration of those who wit- 
nessed his proceedings. Up to this period of his career Frere Jacques 
was perfectly ignorant of anatomy: he was not aware of the danger of 
wounding parts, the structure of which was unknown to him : and hence 
he had all the boldness of a man unconscious of danger. In the operation 
hitherto practised by him, called, in the history of his proceedings, his 
original uncorrected operation, he introduced into the bladder a large 
peculiarly-shaped staff, without a groove, and holding it with his left 
hand, he with the right plunged a long dagger-shaped knife along the 
side of the tuber ischii of the left side into the bladder ; having made a 
sufficiently large opening, he next introduced into the bladder a con- 
ductor through the wound, and having carried a forceps along the con- 
ductor into the bladder, he then withdrew the conductor and staff, and 
endeavoured to extract the stone. The staff, as we have already stated, 
had no groove, nor was it used to guide the knife into the bladder. 

Fagon, the king's physician, was deeply impressed with the boldness 
with which Frere Jacques performed his operation, and being himself 
afflicted with the stone, he formed the resolution of allowing Frere 
Jacques to operate on himself; and partly perhaps with that view, and 
partly from admiration of his boldness and benevolence, he invited him 
to return to Versailles, and kindly inducing him to live in his house, 
persuaded him to study anatomy, and to make dissections under the 
direction of the celebrated Du Verney. Frere Jacques operated on the 
dead body, and the parts were then dissected by Du Verney, who, to- 



550 HISTORY OF PERINEAL LITHOTOMY. 

gether with Fagon and Felix, the king's physician and surgeon, pointed 
out to him the dangers against which he had to guard ; and the result 
was that they induced him to perform what is called his second, or im- 
proved operation, which differed from the former in the use of a grooved 
staff for conducting the knife into the bladder. This operation he 
practised on the dead body, in the presence of his three friends, until 
Du Verney pronounced his experiments on the dead body perfect ; and 
his success on the living body was such that he at one time cut thirty- 
eight persons without losing a single patient. Such is the history of 
Frere Jacques's improved method, which has always been considered as 
the foundation of the very superior mode of perineal lithotomy practised 
in the present day. 

A celebrated writer gives the following account of an event which 
occurred about this part of Frere Jacques's career, and exercised great 
influence on public opinion with reference to his operation. 

" There were at this moment two men of eminent rank who had re- 
solved to submit to the operation of Frere Jacques ; the one, Mr. Fagon, 
first physician to Louis XIV., the other the Mare'chal de Lorges ; both 
had taken measures to insure the success of the operation ; but in the 
very moment that Frere Jacques was about to obtain the most dis- 
tinguished honour, he suffered a sad reverse of fortune. Mr. Fagon 
had himself taught Frere Jacques, and with the assistance of Du Verney, 
the celebrated anatomist, and Felix, first surgeon to the king, had made 
him go through a series of dissections. His operation was reformed 
according to their desire ; he had forsaken his big round staff, and cut 
upon a grooved one ; he had operated on thirty patients in the Hotel 
Dieu of Versailles with uninterrupted success ; he had already sounded 
Fagon, and felt the stone ; yet Fagon, though thus far advanced in this 
generous design, was prevailed on, by the solicitation of his friends, to 
put himself into the hands of Mare'chal, who had learned to perform 
Frere Jacques's operation. Mare'chal accordingly performed the opera- 
tion, and Fagon survived, and in a few weeks went abroad in his carriage. 
The Marechal de Lorges, of distinguished rank and great fortune, pro- 
ceeded with equal precaution ; he assembled in his hotel twenty-two poor 
people afllicted with the stone, who were cut by Frere Jacques with 
perfect success : but while the poor patients survived, the Mare'chal 
himself died in tortures the day following the operation. This was de- 
cisive of the fate of our operator. The Mare'chal de Lorges lying dead 
in his superb hotel, while Fagon, cut by Marechal, was rolling in his 
chariot in the streets of Paris, was a triumph for the regular lithotomists, 
and a mortal blow to the reputation of Frere Jacques, who now departed 
from Paris never to return." 

Frere Jacques operated on nearly five thousand patients in all ; he 
was benevolent, candid, and disinterested; he never accepted more 
money for his services than was necessary to mend his shoes and to 
sharpen his instruments. He operated with astonishing success in diffe- 
rent parts of France ; also at Amsterdam, where he was presented with a 
gold medal for his public services ; at the Hague, where he received a 
present of gold sounds, which it is said he afterwards had melted to give 
to the poor : and at Delft, Leyden, Padua, and many other places ; after 



HISTORY OF PERINEAL LITHOTOMY. 551 

which he went to Rome, to receive the benediction of the Pope, and then 
returning to his native village, at an advanced period of life, he distri- 
buted among the poor what little money he possessed, and died, accord- 
ing to Morand, in June, 1714. 

RAU'S OPERATION. 

Rau, Professor of Anatomy at Leyden, and teacher of the celebrated 
Albinus, was the next great lithotomist that appeared. He had seen 
Frere Jacques operate, and had himself operated with great success ; 
but he refused to tell any one his mode of proceeding, and died without 
leaving any description of it. From the account which Albinus gives 
of it, it is believed that its peculiarity consisted in cutting into the 
bladder behind the prostate, and dividing the prostate by cutting from 
behind forwards, instead of (as in Frere Jacques's improved operation) 
from before backwards. In this proceeding, a grooved staff was used. 

cheselden's operation. 

The celebrated Cheselden, surgeon to St. Thomas's Hospital, London, 
being deeply impressed with the success of the operations of Frere 
Jacques and Rau, resolved to abandon hypogastric lithotomy, or, as he 
called it, of cutting into the bladder by the highway, and to perform 
perineal lithotomy. From Cheselden's own description of his proceed- 
ings, contained in the appendix to different editions of his " Anatomy," 
and from the account of the operation as he at one time practised it, 
given by Douglas, who states that he received it from Cheselden him- 
self, — it is perfectly clear that when he first practised perineal litho- 
tomy, after making his incision in the perineum, he endeavoured to cut 
into the under part of the lateral region of the bladder, and then fixing 
his knife in the staff, he divided the prostate gland, and neck of the 
bladder from behind forwards. This method, however, he afterwards 
abandoned, as being not only difficult of performance, but also unsuc- 
cessful, chiefly from sloughing and infiltration of the cellular tissue. 

Cheselden's second operation has been uniformly regarded as supe- 
rior to any adopted before his time ; and, indeed, with slight modifica- 
tions, it is nearly the same as that practised by most of the best litho- 
tomists at the present day. On this subject, the lamented Mr. Liston 
wrote, as his deliberate opinion, — and, in former days, when I had the 
great privilege of being his pupil, I repeatedly heard him make the same 
statement, — " Depend upon it that, somewhat modified, it is the best 
operation that can be performed ; it is one I have practised with 
little alteration for many years, and in not a few cases, and I see no 
reason to change it for any other." The following is Cheselden's account 
of his second operation, as I find it given by him at page 330, of the 
thirteenth edition of his work on Anatomy now before me. 

" I first make as long an incision as I can, beginning near the place 
where the old- operation ends, and cutting down between the musculus 
accelerator urinae and erector penis, and by the side of the intestinum 
rectum. I then feel for the staff, holding down the gut all the time, 
with one or two fingers of my left hand, and cut upon it in that part of 
the urethra which lies beyond the corpora cavernosa urethras, and in 



552 



HISTORY OF PERINEAL LITHOTOMY. 



the prostate gland, cutting from below upwards^ to avoid wounding the 
gut ; and then passing the gorget very carefully in the groove of the 
staff into the bladder, bear the point of the gorget hard against the 
staff, observing all the while, that they do not separate and let the 
gorget slip to the outside of the bladder ; then I pass the forceps into 
the right side of the bladder, the wound being on the left side of the 
perineum, and as they pass, carefully attend to their entering the blad- 

; Fig. 208. 




der, which is known by their overcoming a straightness which there will 
be in the place of the wound ; then, taking care to push them no further 
that the bladder may not be hurt, I first feel for the stone with the end 
of them, — which having felt, I open the forceps, and slide one blade 
underneath it, and the other at top ; and if I apprehend the stone is 
not in the right place of the forceps, I shift it before I offer to extract ; 
and then extract it very deliberately, that it may not slip suddenly out 
of the forceps, and that the parts of the wound may have time to 
stretch, taking great care not to gripe it so hard as to break it ; and 
if I find the stone too large, I again cut upon it as it is held in the 
forceps." 

Cheselden's success was very remarkable ; on this point, he says, 
" What success I have had in my private practice, I have kept no ac- 
count of, because I had no intention to publish it, that not being suffi- 
ciently witnessed. Publicly in St. Thomas's Hospital, I have cut two 

Fig. 209. 




hundred and thirteen ; of the first fifty only three died : of the second 
fifty, three ; of the third fifty, eight ; and of the last sixty-three, six. 
Several of these patients had the small-pox during their cure, some of 
whom died, but I think, not more in proportion than usually of that dis- 
temper ; these are not reckoned among those who died of the operation. 
The reason why so few died of the first two fifties was, at that time few 



HISTORY OF PERINEAL LITHOTOMY. 553 

bad cases offered ; in the third, the operation being in high request, 
even the most aged and most miserable cases expected to be saved by 
it, and besides, at that time I made the operation lower, in hopes of 
improving it, but found I was mistaken." 

sir c^esar Hawkins's mode. 

The next important change in the mode of proceeding among the sur- 
geons of this country was that introduced by Sir Caesar Hawkins, sur- 
geon to St. George's Hospital, who, having an edge put upon the blunt 
gorget of the apparatus major, thereby converted it into a cutting 
gorget ; and after cutting with the knife into the membranous portion 
of the urethra, he effected an opening into the bladder by dividing the 
prostate with the gorget. After this method became known, many 
different forms of gorgets and gorgerets w T ere invented ; which it would 
answer no useful purpose to describe. Of one of them, Mr. Liston 
remarks, " It is more like an implement for cutting turf, — a ' flauchter- 
spade,' — than for performing a delicate surgical operation." Of other 
instruments invented for dividing the prostate,' and cutting into the 
bladder some of the most celebrated were the bistouri cache'e of Cosme ; 
the gorgeret cistotome-dilatoire-compose' of Le Cat ; and the double 
lithotome, used by Dupuytren, in his bilateral section. 

[" The gorget is fast falling into desuetude. Whether this is owing to 
any intrinsic defect in the instrument itself, or merely to the manner of 
using it, cannot be easily determined. However this may be, very few 
operators, either in this country or in England, continue to employ it. 
Dr. Dudley, of Lexington, has performed all his operations, upwards of 
two hundred in number, with it ; and I am told that he still uses the 
same instrument with which he commenced his brilliant career as a 
lithotomist, forty years ago. Dr. Gibson, of Philadelphia, also adheres 
to the gorget, and so do likewise a few of the other surgeons of that 
city. Most American operators prefer the knife, which is also the case 
in England, France, and other portions of continental Europe. The 
gorget has undoubtedly committed many blunders, the recital of which 
would form one of the most sickening chapters in the history of surgical 
wrongs. Nevertheless, it has done, and still continues to do, good ser- 
vice in the hands of some of our most eminent men, and ought not, 
therefore, perhaps, to be spoken of too lightly or severely, for its faults 
are, perhaps, after all, rather attributable to the surgeon than to the 
dumb instrument with which he does his bungling work. 

" The gorget has sometimes slipped into the cellular tissue between 
the bladder and the rectum, or between this organ and the pubes ; 
thereby bruising and otherwise injuring the parts, and favouring the 
occurrence of. urinary infiltration. Cases are mentioned, where, by a 
blind and heroic thrust, the instrument completely severed the bladder 
from its connexions, pierced the rectum, or penetrated the peritoneal 
cavity, and passed high up among the bowels. Mr. John Bell, in his 
History of Lithotomy, says, ' I have seen the gorget driven twice, not 
into the bladder, but deep among the bowels ; for although there was a 
stone, the surgeon never reached the bladder. Not one drop of urine 
followed ; the stone was not extracted ; and the boy died the second day 



554 



HISTORY OF PERINEAL LITHOTOMY. 



from the operation.' Sir James Earle observes that he has more than 
once known this instrument, though passed in the right direction, pushed 
on so far, and with such violence, as to go through the opposite side of 
the bladder. Mr. Benjamin Bell found in two instances, on dissection, 
that this organ was wounded in three different parts, at its neck, in its 
side, and towards its superior fundus. The late Mr. Crosse states that 
he has repeatedly seen the gorget slip between the bladder and the rec- 
tum ; in one instance he declares that the instrument, after entering the 
bladder, pierced its coats from within outwards, so as to stop against 
the pubic bone. Bromfield, i*a passing the gorget, perforated the 
opposite side of the bladder, and found, to his horror, on withdrawing 
the instrument, that the intestine had descended through the opening. 
The bowel had to be held out of the way while he extracted two calculi, 
though it was forced out again by the child's screaming before he at- 
tained his object. ' As soon as he was convinced, by his finger, that 
the bladder was totally free from any pieces of stone, he again returned 
the intestine into the pelvis, and brought the child's thighs close together ; 
a piece of dry lint was applied to the wound, and a pledget over it ; he 
was then sent to bed with no hopes of his surviving till the next day ; 
but, contrary to expectation, the child had a very good night, and was 
perfectly well in little more than a fortnight.' It is said that the cele- 
brated Scarpa thrust the gorget, which was looked upon as the palladium 
of his fame, between the bladder and the rectum. 

"The operation with the gorget differs, in no wise, in its early stages, 
from the operation with the knife. The period for using the instrument 
is immediately after the incision of the membranous portion of the ure- 
thra. The surgeon then exchanges the scalpel for the gorget, the beak 
of which he places in the groove of the staff, guided by the point of the 
left index-finger. After assuring himself, by drawing the instrument 
slightly backwards and forwards, that it is in no danger of slipping, he 

Fig. 210. 




takes hold of the handle of the staff, and by a simultaneous movement of 
his hands, he lowers the instrument and the gorget nearly to a level with 
the abdomen ; pushing at the same time the latter onward into the blad- 
der. In executing this part of the operation, care should be taken not 



HISTORY OF PERINEAL LITHOTOMY. 555 

only that the gorget do not slip out of its place, and thus pass between 
the rectum and the bladder, but that it is properly lateralized, otherwise 
there will be great risk of injury to the rectum and the pudic artery. 
The annexed engraving represents the gorget, as modified and improved 
by Physick and Gibson." (From Gross on Urinary Diseases, &c.) — Ed.] 



Sectio-bilateralis. — The bilateral section of Dupuytren consisted in 
making a semilunar incision, having its convexity forwards, and extend- 
ing from between the anus and the tuberosity of the ischium on the one 
side, to the corresponding part on the other ; in continuing the dis- 
section so as to divide all the parts over the membranous portion 
of the urethra, and opening this membranous portion for a short 
distance from before backwards ; after which, the double lithotome 
was fixed in the groove of the staff, and by it conducted into the blad- 
der ; then, the staff having been withdrawn, the concavity of the litho- 
tome was directed downwards, the blades were expanded, and in with- 
drawing the instrument, the double section was effected. A double 
reason in favour of this proceeding is, that there is no risk of wounding 
the rectum, nor of injuring the pudic arteries, unless the blades be ex- 
panded to an unnecessary extent. 

[" The bilateral operation of lithotomy has never had any distinguished 
advocates in Great Britain, where the ordinary method seems to be uni- 
versally preferred to all others. Nor has it, so far as I am informed, 
received much countenance in Germany, Russia, and Italy. It was first 
performed in this country in 1832, by Dr. Ashmead, of Philadelphia. 
It was repeated soon after by Dr. Ogier, of Charleston ; and within 
the last ten years has been practised by Stevens, Warren, Mussey, Eve, 
Parker, Watson, Hoffman, Post, May, Pancoast, and other surgeons. 
It was also, as I am informed, the favourite method of the late Dr. 
Bushe, of New York. I have myself been so much wedded to the lateral 
method that I have never felt inclined to employ any other. 

" Most of the surgeons above named use the knife, both for dividing 
the perinseum and the prostate gland. My distinguished friend, Pro- 
fessor Eve, of Georgia, who is one of the most able and strenuous advo- 
cates of the bilateral method, informs me that he always employs the 
lithotome cache' of Dupuytren. Of fourteen patients cut with this in- 
strument, only one died, but from no cause connected with the opera- 
tion. Dr. Stevens, of New York, has devised an instrument, named the 
prostatic bisector, which he uses for cutting the prostate gland and neck 
of the bladder. An instrument very much on the same plan had been 
previously contrived by Dr. Pattison and Dr. Bushe. Dr. Mussey, of 
Cincinnati, formerly employed the lithotome cache', but of late years, as 
he has recently informed me, he has given a decided preference to the 
knife. The last twenty-three operations which he has performed were 
done in this manner. 

" The double lithotome was greatly improved by Dupuytren, and is 
accurately represented in the annexed drawing. ' It consists of two 
long, narrow blades, folding upon each other, and concealed in a 



556 



L I T PI T E I T Y. 



Fiff. 211. 



case, which is slightly curved, and adapted, by its size and shape, to be 
passed along the groove of the staff into the bladder. Thus, the instru- 
ment is introduced through the urethra without injury to the parts, 
while a mechanical contrivance attached to the handle allows the blades 
to be expanded after it has been lodged in the bladder. They quit the 
sheath on each side, and, when separated, resemble the blades of a pair 
of scissors with the cutting edges reversed. In this state the instrument 
is withdrawn, and cuts its way out. The size of the opening produced 
of -course depends upon the extent to which the blades 
have expanded, their degree of separation being indicated 
by an index.' ,n (Gross on Urinary Diseases, &c.) — Ed.] 
It is hoped that from the preceding account may be 
clearly understood the mode of performing lithotomy 
adopted by some of the most distinguished surgeons of 
the present day, as well as the principal methods we 
read of in the history of the operation, and their most 
important varieties. Besides the median, lateral, and 
bilateral modes of perineal lithotomy, quadrilateral 
lithotomy has been proposed, in certain circumstances, 
by M. Vidal de Cassis, but it is unnecessary to describe 
this proceeding. 



LITHOTRITY. 



This term is now used to designate the operation 
of boring or rubbing a calculus in order to pulverize 
it, and so remove it through the natural passage. 
The first person in modern times who adopted proceed- 
ings with that view, was General Martin, who, in 
1800, operated on himself, and, by means of a file, 
removed part of a stone with which he was afflicted. In 
1813, Gruithuisen proposed the use of a canula through 
which a borer was introduced ; and after him, several 
others who had devoted attention to the subject, made 
various suggestions, possessing more or less ingenuity. 
But M. Civiale, in 1823, proposed a more ingenious 
apparatus than any of his predecessors. This consisted 
of an outward canula containing three branches, which, 
when thrust out, after its introduction into the bladder, 
seized and held the stone, on which, when thus firmly 
fixed, a drill, sent through the inner canula, was made 
to act. The result, however, of this, and of all other 
proceedings on the same principle, was far from satis- 
factory, and; in consequence, the present practice is to 
crush the stone, instead of drilling it, — or, in other 
words, Lithotrity has been superseded by Lithotripsy. 



Brit, and Foreign Med. Rev., vol. ii. p. 101. 



LITHOTRIPSY. 557 



LITHOTRIPSY. 



The operation known by this name, for removing calculi by crushing, 
has now been brought to great perfection. To the late Mr. Weiss, sen., 
undoubtedly belongs the merit of having invented, and offered to the 
profession, the first lithotriptor, on the principle of that now in common 
use; and Mr. Weiss, jun., brought the instrument to its present state of 
great simplicity and perfection. On the recommendation of Mr. Liston, 
Mr. Weiss made the handle of metal, instead of wood or ivory, with 
which it had before been covered, — a change by which the percep- 
tion of the contact of the instrument with the calculus is rendered 
much more delicate. At the suggestion, as Mr. Liston informs us, 
of Mr. Oldham, a gentleman connected with the Bank of England, 
Mr. Weiss introduced another most important alteration, without which 
the use of the instrument was more hazardous : — he made the outer 
blade open, so as to receive the other. The accompanying draw- 
ing is a representation of the simple and perfect lithotriptor, now in 

Fig. 212. 




use. Mr. Weiss states that he showed his lithotriptor to many profes- 
sional men, and among others, to Baron Heurteloup in 1830, who, up 
to that time, had used the straight drill of Civiale ; he immediately 
adopted the invention, and merely substituting the hammer for the screw, 
claimed it as his own, calling it his " Percuteur Courbe a Marteau." 

[" Another instrument, the merits of which are certainly equal, if not 
superior, to those of the one just described, is that of Dr. Jacobson, an 
eminent surgeon of Copenhagen. For simplicity and facility of use, it 
would be difficult to conceive of anything more perfect or convenient. 
It consists of a silver canula, about ten inches long by three lines in 
diameter, the upper extremity of which is furnished with a circular steel 
rim, an inch in width, while the lower is slightly curved for about two 
inches, and terminates in a blunt point. Within this tube is a steel 
rod, calculated to move backwards and forwards at pleasure, and con- 
nected, inferiorly, with the one just described by means of an articu- 
lated chain consisting of three links. The superior extremity projects 
beyond the horizontal rim of the canula, and is furnished with a stout 
screw, which is intended to work the chain backwards and forwards, 
during the seizure and comminution of the stone. A graduated scale 
exists upon the instrument for measuring the volume of the stone. 

" It has been alleged that the lithotriptor of Jacobson is inferior, in 
several respects, to that of Heurteloup and Weiss ; but, mainly, on 
account of its greater liability to pinch the coats of the bladder, and 



558 



LITHOTRIPSY. 



Fig. 213. 



its inability to grasp so large a calculus. It is also said to be more 

difficult to seize the concretion so readily when 
it lies behind the prostate in a cul-de-sac of the 
bladder. These objections, however, are rather 
imaginary than real. In the first place, it is 
not an easy matter for a skilful surgeon, in any 
case, to include the coats of the bladder in the 
jaws of his instrument ; the contingency, at all 
events, is a remote one, and can scarcely hap- 
pen if care be taken to round off the margins 
of this part of the instrument ; secondly, no 
calculus larger than what can be embraced by 
Jacobson's lithotriptor should ever be attempted 
to be crushed by this operation ; and, lastly, if 
the stone lies low in the bas-fond of the blad- 
der, and cannot be readily seized, the difficulty 
is easily remedied by the introduction of the 
finger in the rectum. These objections, there- 
fore, fall to the ground. Fig. 213 represents 
Jacobson's stone-crusher, as modified by Vel- 
peau. 

" With either of the above instruments the 
operation may, in general, be safely and expe- 
ditiously performed. The percussor of Heur- 
teloup, is, I believe, but rarely used anywhere 
at the present day ; it is an awkward and clumsy 
affair, and ought, in my judgment, to be dis- 
carded from our armamentarium. 

" It is not every case of stone that admits of being crushed. There are 
certain circumstances which imperatively forbid it ; and hence much 
judgment is frequently required to. enable the surgeon to make a proper 
selection. When the operation was in its infancy, there is reason to 
believe that it was too often employed indiscriminately, both to the 
detriment of patient and surgeon ; and, on the other hand, many per- 
sons were doubtless subjected to lithotomy who would have made excel- 
lent subjects for lithotripsy. Fortunately, a better state of things pre- 
vails at the present day ; the jealousy which existed between the 
stone-breaker, and the knife-man, has ceased ; and the consequence is, 
that more judgment is displayed in the selection of cases for the two 
operations. In this country, however, lithotripsy is still in its infancy ; 
in fact, it can hardly be said to have received fair play from the hands 
of the lithotomists. Dr. Dudley, who has operated more frequently for 
stone than any surgeon in America, has never, I believe, employed litho- 
tripsy ; and the same is true of some of our other practitioners. Those 
who have busied themselves most with this operation, in this country, 
are Dr. Randolph, Dr. Gibson, and Dr. Pancoast, of Philadelphia, and 
Dr. N. R. Smith, of Baltimore ; the first of whom unfortunately died 
too soon for the cause of surgery, which he was so nobly engaged in 
cultivating. Many other surgeons have occasionally resorted to it, but 
comparatively few have made it the subject of their special study and 




LITHOTRIPSY. 



559 



practice. The operation was first performed in the United States, by 
Dr. Depeyre of New York." (Gross on Urinary Diseases, &C.) 1 — Ed.] 
When the operation is to be performed, the patient is placed on a 
couch or bed of convenient height, with a pillow below the pelvis, so as 
to send the stone into the fundus of the bladder. If the bladder should 
not contain a sufficient quantity of urine to distend it, so that the stone 



may be crushed without injury to the 

Fig. 214. 



lining 



membrane, tepid water 




should be injected by means of a syringe and catheter, until the bladder 
contains at least six or seven ounces of fluid. The lithotriptor having 
been then introduced, and the stone seized, the surgeon, after previously 
ascertaining that no portion of the lining membrane is entangled, brings 
the stone to the centre of the viscus, and commences the crushing pro- 
cess by turning the screw ; this should be done very gradually, espe- 
cially at first. The crushing of the stone is felt by the operator very 
distinctly. If the stone be very small and friable, it may be pulverized 
at one seizure ; but more frequently it happens that, after the first 
crushing, the fragments require to be seized and pulverized. 

When one seizure is insufficient, the surgeon must be guided by the 
susceptibility of the patient in judging how frequently it may be repeated 
at one time, as, if a very correct judgment be not formed on this point, 
and if the crushing be carried to too great an extent, very serious con- 
sequences are likely to result. When the process has been continued 
as far as may be necessary, or as the state of the patient may render 
advisable at one time, a large catheter, with a peculiar opening at its 
extremity, is introduced, through which the urine and some of the 
detritus are discharged ; and if considered at the time desirable, a little 
water may be injected once or twice, by means of a syringe, before the 
removal of the catheter, in order to favour the escape of detritus, it 
being important to bring off as much as possible through the instrument, 

1 New York Med. Jour., for February, 1831. 
Fix- 214. From Liston. 



560 LITHOTRIPSY. 

as the transmission by this means occasions no irritation. Rest and 
antiphlogistic treatment should be strictly enjoined, and the local symp- 
toms which supervene, must be treated according to the common princi- 
ples of surgery. Fragments pass off for some days, and in their trans- 
mission through the urethra often give rise to great pain and irritation. 
If another operation be necessary, it may be ventured on after the 
effects of the first have disappeared. The cases favourable for Litho- 
tripsy are those of adults in whom the stone is small and compara- 
tively soft, the kidneys, bladder, prostate gland, and urethra, organically 
sound and free from any particular irritability, and the general consti- 
tution not more than ordinarily susceptible. There can be no doubt 
that in such circumstances lithotripsy, in the hands of a judicious sur- 
geon, is a very safe and satisfactory operation ; and that when these 
favourable conditions combine, it is to be preferred to lithotomy ; but 
in other circumstances, supposing an operation to be desirable, lithotomy 
is undoubtedly that which ought to be adopted. If in all cases a cor- 
rect and unprejudiced judgment be exercised, first as to whether any 
kind of operation be advisable, and if so, then whether in the particular 
conditions of each case lithotripsy or lithotomy be the more suitable 
operations for the removal of calculi in the bladder, will be found suffi- 
ciently satisfactory in their results. It is only the abuse of these opera- 
tions that can bring either the one or the other into discredit. 



561 



CHAPTER XVI. 

AFFECTIONS OF THE TESTICLE. 

ORCHITIS. 

Inflammation of the testis may be either acute or chronic : it may 
commence in the body of the testicle, or in the epididymis, forming the 
epididymitis of some authors ; and it may be either primary, as when 
idiopathic, or when excited by external violence* such as a bruise, a 
wound, or exposure to cold and wet ; or, as is far more frequently the 
case, consecutive, the inflammation being transmitted from the urethra 
by spreading along the vas deferens, or perhaps by metastasis, — in which 
circumstances the epididymis is first attacked and most affected, the 
tunica vaginalis generally becoming soon involved. An example of 
orchitis as thus induced has been referred to in the enumeration of the 
consequences of gonorrhoea, a form of the disease usually acute, and 
known by the names of " secondary gonorrheal orchitis," or "hernia 
humoralis." Secondary orchitis may, however, be the result of inflam- 
mation unconnected with gonorrhoea ; it may arise from inflammation 
caused by violence in the introduction of catheters or bougies, or it may 
be the consequence of strictures, or of the means used to cure them. 
Sometimes it is an accompaniment or a consequence of mumps, in which 
case its production depends on metastasis. 

ACUTE ORCHITIS. 

Symptoms. — When orchitis is primary and acute, the symptoms are, 
excruciating pain in the testicle, great tenderness, especially as the 
disease advances, — so that in some cases the patient cannot allow the 
part to be touched, a distressing sense of weight, a swelling of the tes- 
ticle, which, however, preserves its oval form, pain extending along the 
back and in the loins, where it is often extremely severe, and a red, hot, 
shining appearance of the scrotum. The pain and sense of weight are 
increased by the erect posture. In very acute cases, nausea, vomiting, 
and pain in the under part of the abdomen are urgent symptoms, which, 
in consequence of their similarity, have sometimes been mistaken for 
symptoms of enteritis. The most severe form of orchitis is usually that 
which arises from wounds of the testicle. Such injuries are therefore 
very dangerous, especially in individuals of an irritable habit of body. 
The constitutional symptoms in the acute primary form of the disease 
are very severe. 

Consecutive Orchitis, when originating in the transmission of inflam- 



562 ACUTE ORCHITIS. 

matory action by continuity of tissue, is usually preceded by slight pain, 
weariness, and fulness in the groin, where the cord is found to be ten- 
der on pressure, and the vas deferens to be enlarged. These symptoms 
are followed by pain, tumefaction and tenderness of the epididymis, 
which forms an elongated swelling at the back of the testicle ; in many 
instances this swelling is so great as to render the epididymis as large 
as the testis, which remains still unaffected. The inflammation soon 
extends to the tunica vaginalis, when the tumour forms a mass, the 
different parts of which are " no longer distinguishable, and the testis 
itself becomes involved. The distinguishing peculiarities of this form 
are the symptoms along the course of the cord in the first instance, fol- 
lowed by the affection of the epididymis, which invariably precedes that 
of the testis ; — the cord, epididymis, tunica vaginalis, and testis becom- 
ing successively affected. In this variety the swelling is usually greater, 
and forms more rapidly ; and although there is much variety in the 
intensity of the symptoms, the pain and constitutional disturbance are 
for the most part less severe. 

In the sympathetic form of gonorrhoeal orchitis, namely, that in which 
the disease presents itself without any previous affection of the vas 
deferens — a variety sometimes met with, although rare in comparison 
with the last-mentioned form of the disease — there is an absence of all 
symptoms indicating any affection of the cord, and the inflammation 
commences in the epididymis. 

In by far the greater number of cases of gonorrhoeal orchitis the 
inflammation proceeds along the vas deferens to the epididymis. In 
seventy-three cases out of one hundred and four noticed by M. Aubry, 
the inflammation first attacked the vas deferens ; in the remaining 
thirty-one the disease was sympathetic. 

Gonorrhoeal orchitis may occur at any period of an attack of gonor- 
rhoea ; but it most frequently commences when the pain and discharge 
begin to subside. On the connexion supposed to exist, between the in- 
flammation of the testis and the state of the discharge, the under-men- 
tioned authorities give the following result of their observations. M. 
Gaussail states, that in sixty-seven cases out of seventy-three, the gonor- 
rhoea diminished on the first appearance of orchitis ; M. Aubry, that in 
fifty-eight cases out of eighty-one, there was diminution of discharge at 
the commencement of inflammation of the testicle ; and M. D'Espine. 
mentions that in only six cases out of twenty-nine the discharge con- 
tinued unchanged ; while in the remaining twenty-three, it was variously 
modified, being increased in some, diminished in others, and in others 
entirely suppressed. 

Late observations have shown the incorrectness of the opinion which 
at one time prevailed, that? secondary orchitis is more frequent on the 
left side than on the right. Of seventy-three cases mentioned by M. 
Gaussail, forty-five were on the right side, twenty-four on the left, and 
four were double ; of twenty-nine observed by M. D'Espine, twelve were 
on the right side, eleven on the left, and six double; and of thirty-six 
which occurred in the practice of Mr. Curling, twenty-one were on the 
right side, fourteen on the left, and only one double : so that of one 



CHRONIC ORCHITIS. 563 

hundred and thirty-eight cases it appears that seventy-eight were of the 
right testicle, forty-nine of the left, and eleven of both. 

Treatment. — The local treatment of acute orchitis consists in the use 
of leeches, rest, recumbency, support of the testicle, so as entirely to 
obviate the effects of gravitation, and warm fomentations. Opening a 
vein in the scrotum is often a convenient mode of local depletion. When 
the tunica vaginalis is involved and much pain is experienced from ten- 
sion, great relief is often experienced from evacuating the accumulated 
serum. Cold evaporating lotions sometimes give more relief than warm 
fomentations or poultices ; the feelings of the patient are the surest 
guide, whether the warm or the cold are preferable. 

The constitutional treatment consists in the use of low diet, rest, the 
free exhibition of antimony, general depletion when the inflammatory 
symptoms and sympathetic fever are urgent, and after the pulse has 
been lowered by antimony, and other means, resolution is often pro- 
moted, and structure saved, by the use of mercury. Both in the idio- 
pathic form, when the testicle is principally involved, and in the conse- 
cutive, when the inflammation has its seat principally in the epididymis 
and tunica vaginalis, mercury is exceedingly useful : some surgeons 
confine its use almost entirely to primary, and others to secondary 
orchitis. I have used it pretty generally in both classes of cases, and 
am perfectly convinced that much advantage results from doing so. As 
inflammation originating in the testicle is not only more painful and at- 
tended with more constitutional disturbance, but also more apt to 
endanger the structure and function of the part affected, this form of 
orchitis requires even more prompt and decided treatment than the 
others. If suppuration should occur, which is more apt to take place in 
primary than consecutive orchitis under proper treatment, free incision 
should be made as soon as there is decided evidence that matter has 
formed ; by this proceeding the tubular portion of the organ will be less 
endangered, and sinuses and fistulous passages probably prevented. 

When the disease has become chronic, the greatest benefit is often ex- 
perienced from the cautious employment of pressure, applied by means 
of adhesive plaster cut into strips, the testicle being separated from its 
fellow, and the scrotum drawn off as much as possible from the diseased 
testicle, to admit of the proper application of the strips of plaster. Of 
the advantages of this treatment in chronic cases, I can speak in the 
strongest terms. Dr. Fricke of Hamburgh suggested treatment by com- 
pression, both in acute and chronic cases, and states as the result of 
that proceeding, that of fifty-one cases of acute orchitis, eighteen having 
been treated in the ordinary method, and thirty-three by compression, 
the average duration of the disease in the former was thirteen days, in 
the latter only nine days. Ricord, Cullerier, Parker, Acton, Curling, 
Hamilton, and others, have spoken favourably of the results of this 
practice ; but in acute cases I have had no opportunity of forming a 
judgment upon it from my own personal observation. 

chronic orchitis; or, fungus of the testicle. 

This affection occasionally succeeds acute orchitis, as a result of the 
inflammation being imperfectly resolved ; but it is much more frequently 



564 CHRONIC ORCHITIS. 

chronic from its ■ commencement. By far the most frequent cause of 
chronic orchitis is urethral disease, such as gonorrhoea, or stricture, the 
inflammation being conveyed along the vas deferens to the epididymis. 
Irritation of the urethra, induced by other affections of the urinary 
organs, is sometimes the exciting cause. It ought, however, to be 
remembered, that this disease is not invariably owing to the state of the 
urethra. Excessive indulgence of the passions, a reduced state of the 
vital powers, debility resulting from a long-continued course of mer- 
cury, are all regarded as predisposing causes. It has been sometimes 
known to come on during attacks of gout and rheumatism ; and hence 
these diseases have been said to be favourable to its occurrence. 

Anatomical characters. — The principal anatomical character of this 
disease is a yellow homogeneous deposit which does not become vascular, 
and which is at first soft, but ultimately becomes more solid and firmly 
adherent to the parts with which it is in contact. This deposit is the 
ordinary result of the various forms of the disease, and on it the enlarge- 
ment depends. Pathologists have been anxious to determine in what 
textures the matter is originally deposited. 

Cruveilhier, who has given an interesting description of this disease, 
illustrated by coloured plates, supposes that the yellow substance is 
originally deposited in the cellular tissue of the testis, and that it radiates 
along the fibrous partitions from the corpus Highmori. But although 
in very advanced cases it may be found in the cellular tissue, yet, from 
the dissections of Sir Astley Cooper, Sir Benjamin Brodie, Mr. Curling, 
and many others, it appears certain that it is originally deposited within 
the tubuli testis, and that it is a secretion in them by the lining mem- 
brane. It has been found in them, in the rete testis, the epididymis, 
and the vas deferens. 

The disease may give rise to serous effusion into the tunica vaginalis, 
producing fluctuation ; or to effusion of lymph, causing obliteration of 
the sac, or to ulceration of the coats of the testicle, and of the parietes 
of the scrotum, and to eventual protrusion, through the opening, of a 
yellowish, firm, comparatively painless fungus, which, being part of the 
testicle itself, the condition has very properly received the name of 
Hernia testis. In many cases the surface of the protruded part becomes 
covered over with a layer of weak granulations, affording a copious dis- 
charge ; but in many which I have seen no granulations were formed. 
The tumour consists of the tubuli testis with the yellow deposit, the part 
being pressed out by the morbid deposit when resistance can no longer 
be offered by the coats of the testicle, and the parietes of the scrotum, 
they having given way by ulceration. In some instances, the whole of 
the organ has protruded. The protrusion may or may not be preceded 
by slight suppuration, as well as by the yellow deposit, and sometimes 
pus is deposited in various parts, giving rise to abscesses and sinuses ; 
and creating a necessity for castration. 

Such are the anatomical characters of chronic orchitis, when it runs 
its course. 

Symptoms. — The principal symptoms of this disease are slight pain, 
or a sense of uneasiness, or weight in the part. The uneasiness, how- 
ever, is not great, and in some instances is so slight that the disease has 



IRRITABLE TESTIS. 565 

been known to make considerable progress before the patient has been 
aware of its existence. The testicle feels hard and incompressible. 
The hardness and pain are both greater before the coats of the testicle 
have given way, than afterwards. There is slight tenderness or 
pain on pressure, at the commencement of the inflammatory process; 
but after the disease has existed for some time, the tenderness on pres- 
sure is very inconsiderable, and (what is very remarkable), when, at an 
advanced stage of the disease, protrusion of the substance of the testicle 
has taken place, it is found to be nearly, if not entirely, insensible. If 
suppuration precede protrusion, the patient will exhibit the ordinary 
local signs of inflammation. The suppuration is always limited, as is 
also the softening which it induces. The general swelling usually dimi- 
nishes to a certain extent, when the scrotum has given way. 

Treatment. — The result of treatment is usually satisfactory, if com- 
menced at an early period. It may be said to consist in the removal of 
the cause of the disease, rest, a course of mercury carried to an extent 
sufficient to produce an impression on the system, and the careful 
employment of pressure by the mode already described. Mercury is 
the grand remedy, and in few diseases is more benefit derived from its 
use. Blue pill, alone or in combination with opium, as symptoms may 
indicate, is one of the best modes of administering it. In many cases 
I have used the proto-iodide of mercury in doses of a grain and a half 
night and morning, and with the most beneficial results. During an 
accession of inflammatory symptoms, local depletion by leeches may be 
necessary, but depletion forms no prominent part of the treatment of 
this disease. When protrusion has taken place, the mode of treatment 
now adopted is that for which we are indebted to Professor Syme. It 
consists in slightly enlarging the opening through which the protrusion 
has taken place, removing the hard ring of integument which consti- 
tutes the margin of the opening, bringing the integument completely 
over the protruded part, and retaining the opposite sides of the opening 
in apposition by means of sutures. This treatment has now been fairly 
tried in many cases, and, as far as I know, has been uniformly attended 
with the desired result. It is certainly a great improvement on the 
practice which formerly prevailed, namely, that of shaving off the 
fungus, or destroying it by escharotics, and endeavouring afterwards to 
heal the wound; — a treatment, in some instances, so tedious and unsa- 
tisfactory, that castration has often been deemed more expedient. 

NERVOUS AFFECTIONS OF THE TESTIS. 

There are two varieties of nervous affections of the testicle, namely, 
"Irritable Testis," and "Neuralgia of the Testis." 

IRRITABLE TESTIS. 

This affection, which is an increase of the natural sensibility of the 
organ, is usually met with in weak, irritable, dyspeptic, and hypochon- 
driacal persons, and is for the most part dependent on some affection of 
the urethra, or of the genital system, or on disorder of the general 
health. It sometimes occurs after great indulgence in sexual inter- 



566 NEURALGIA OF THE TESTIS. 

course, or after much venereal excitement ; and it has been known to 
be a consequence of onanism, and of involuntary seminal emissions. 
The sensibility of the organ is increased to a most painful extent, so 
that in some cases the part is intolerant of manipulation, and even the 
contact of the dress is painful. In some instances both sides are 
affected, a circumstance in which morbid sensibility differs from Neu- 
ralgia of the Testis. The uneasiness is usually increased by exercise, 
and by the erect posture, and is sometimes so great as to oblige the 
patient to abstain from exercise, and to remain at rest in the recumbent 
posture. As this distressing complaint yields to treatment, castration 
is not necessary ; nor would it be always effectual, as the disease has 
been found to return in the cord. In some cases in which patients have 
insisted on castration, opportunity has been afforded of examining the 
condition of the testis, which, in no instance, as far as I know, was 
found to differ from the normal state, except that slight dilatation of 
vessels was in a few instances observed. 

In the treatment of this affection, the principal indications are, to 
remove the cause, to improve the general health by such means as are 
most judicious in the particular circumstances of the case, and to dimi- 
nish the preternatural sensibility of the parts by local bathing, and the 
application of anodyne lotions. Lotions containing opium, belladonna, 
or tincture of aconite, or combinations of these medicines, are often 
exceedingly useful. In several instances this affection has been cured 
by complete change of scene, air, and mental occupation, without any 
other treatment except support of the testis. 

NEURALGIA OF THE TESTIS. 

In this distressing affection there is constant uneasiness, sudden, 
severe, and remittent attacks of pain, occurring in paroxysms of variable 
duration, and generally at irregular but sometimes at regular intervals, 
like other neuralgic pains. The pain is most excruciating, and during 
its continuance the testicle is drawn up by spasmodic contraction of the 
cremaster muscle, and in some instances the pain is attended with nau- 
sea and vomiting. This affection possesses the characters of tic doulou- 
reux, or true neuralgia, and is almost always confined to the spermatic 
nerves of one side. It is most frequently met with in weak, irritable, 
and dyspeptic persons, and attended with a disordered condition of the 
digestive organs ; and the intense pain and want of rest in most cases 
give rise to derangement of the general health. Occasionally this affec- 
tion has been found to succeed an attack of orchitis, and to recur when- 
ever the patient's health has become disordered, and in several cases it 
has been known to be excited by the morbid condition of the veins in 
varicocele : but in the great majority of instances the cause of the 
disease is exceedingly obscure ; and when, on account of the severity of 
the pain, patients have insisted on castration, dissection has not dis- 
covered anything to account for the pain ; for the structure of the testis 
has almost always been found to present a perfectly healthy appear- 
ance, except in some examples, in which there was a slight fulness of 
vessels, the effect probably, and not the cause, of long-continued pain. 
Castration is not advisable, for although in some instances the result 



SCROFULOUS TESTICLE. 567 

has been favourable, in others the disease has returned in the cord ; 
and moreover, the disease usually yields in time to the treatment proper 
for neuralgia in other parts, which has been already described. 

TUBERCULAR DISEASE OF THE TESTICLE, OR SCROFULOUS TESTICLE. 

This disease sometimes occurs in children, a fact, of which a con- 
siderable number of examples are recorded, and of which I have seen 
two, in boys of five and seven years of age ; but it has been found ad- 
vanced to the stage of suppuration at a still earlier period. The most com- 
mon time for its appearance is at puberty, or between that period and 
the age of twenty. It is generally found only in one testicle, but some- 
times both are affected. 

Symptoms. — The patient feels uneasiness in some part, generally in 
the epididymis, where, on examination, enlargement and induration may 
be }^rceived. The hardness is greater than in common chronic orchitis, 
but less than in scirrhous affections of the testicle. In most cases un- 
easiness is afterwards experienced in another part, commonly also in the 
epididymis, and on examination another swelling with the same characters 
is discovered. The disease is always slow in its progress, and often ap- 
pears as if stationary ; but after a considerable period the enlargement 
becomes greater, the uneasiness increases, the integument becomes of a 
dark livid red colour, and adherent to the large part, and at last an ab- 
scess forms, from which pus mixed with tubercular matter is discharged. 
The quantity of matter discharged is not great, the abscess does not 
readily heal, a fistulous opening forms, through which a thin discharge, 
sometimes mixed with seminal fluid, continues to ooze. Sometimes hernial 
protrusion takes place of the tubercular matter. The slight fungus thus 
formed is easily distinguished from protrusion of the substance of the 
gland in chronic orchitis by being much softer, of less extent, and more 
easily broken down. From what will be stated under the head of treat- 
ment it will be evident that the diagnosis in these cases is very important. 
It is not often that the whole testicle is destroyed by the disease ; in the 
great majority of cases a considerable portion of the organ remains in a 
sound state. In an advanced stage of the disease the original humour 
may not be so easily perceived, on account of general swelling caused 
by effusion into the tunica vaginalis. The patient in most instances 
exhibits scrofulous affections in other parts. 

Anatomical Characters. — The swelling presenting the characters 
already described depends on tubercular deposit, the seat of which is 
more frequently in the epididymis than in the testis. Cases have occurred 
in which the entire epididymis has been found to be occupied with this 
deposit, while the structure of the testis was perfectly sound. The 
desposit is met with in various situations, often at the ends of the 
epididymis, the globus major being more frequently affected than the 
minor. It is a question whether tubercular matter is originally formed in 
the tubuli themselves, or in the cellular tissue connecting them together. 
The dissections of various competent observers lead to the conclusion, 
that it may take place both within and without the tubuli. It has been 
found in the interior ducts forming the epididymis, and in the vas defe- 
rens, and sometimes in the processes sent in from the tunica albuginea to 



568 FIBROUS TRANSFORMATION OF THE TESTIS. 

support the lobules composing the testis. In the section on Tubercular 
Tumour will be found an account of the views at present entertained of 
the origin of Tubercular Deposit, together with a description and de- 
lineation of its appearance viewed under the microscope. 

Treatment. — The treatment is both constitutional and local. In this 
as in other scrofulous affections, constitutional treatment is of the first 
importance. The constitutional treatment proper in cases of Scrofulous 
Deposit will be detailed in the section on Tubercular Tumour. With 
regard to the local treatment, support of the testicle is indispensable in 
every stage of the disease. In its first stage, and when the morbid 
action has become chronic, rubbing the part with iodide of potassium 
ointment, or with an ointment of the iodide of potassium and iodine, or 
painting it every second day with tincture of iodine, or strapping the 
testicle with the emplastrum ammoniacum, are suitable local remedies. 
My own experience leads me to prefer painting the part with tincturg of 
iodine in preference to any other application. When local inflammatory 
symptoms present themselves, the most useful remedies are, rest, eleva- 
tion of the testicle, leeches, and cold lotions ; and should suppuration occur, 
early evacuation of the matter by direct incision is important. After 
evacuation of the matter, it is sometimes advisable to destroy the diseased 
parts by means of the nitrate of silver, after which a healing action is 
more readily induced. Should protrusion of the tubular portion occur, 
the treatment of preserving the part and bringing the integument over 
it is not suitable, though so successful in the case of fungus in chronic 
orchitis ; but the protruded part should be destroyed by some powerful 
escharotic, such as the potassa fusa, or the chloride of zinc. Sometimes 
the destruction of the substance of the testis is so extensive from tuber- 
cular deposit, suppuration, and sinuses, as to render ineffectual every 
proceeding except castration. 

FIBROUS TRANSFORMATION OF THE TESTIS. 

The principal symptom of this comparatively rare affection is, great 
induration. In some cases the testis has been found unchanged in size ; 
in some, slightly diminished ; in others enlarged. It is distinguished by 
the absence of pain or any particular inconvenience, by not being of a 
malignant character, and by occasioning little discomfort, except when 
the patient becomes alarmed, and the affection is in consequence a source 
of mental anxiety. I have met with only one example of this disease in 
my own experience ; and in that I was obliged to resort to castration, 
on account of the patient's excessive anxiety, in consequence of which 
his general health had been seriously injured. The only local symp- 
toms in this case were, great induration, slight enlargement, and a sense 
of weight in the affected part. When, from the above-mentioned cause, 
castration is deemed advisable, it may be resorted to with every prospect 
of satisfactory success, as the disease is not of a malignant character. 
No treatment is of any avail, The disease seems to consist in the change of 
the cellular tissue into fibrous, and the new development of fibrous tissue, 
the presence of which causes obliteration and removal of the secreting 
structure. Dissection has revealed two varieties of the disease ; one, the 
more common, in which the testis becomes firm and dense like the fibrous 
tumour of the womb ; and the other, in which the structure is compara- 



CYSTIC SARCOMA. 569 

tively loose, and slightly infiltrated with a serous fluid. The anatomical 
and microscopic characters of fibrous tumour are more particularly de- 
scribed in the chapter on Tumours. 

CYSTIC SARCOMA. 

Symptoms. — This rare affection, called by some hydatid disease of 
the testicle — an improper appellation, inasmuch as the cysts are not of 
the nature of animal hydatids, — is chiefly met with in the middle period 
of life, rarely before the eighteenth or after the fortieth year. It begins 
in the testis, and is unattended with pain, tenderness on moderate pres- 
sure, redness, heat, transparency, enlargement of the cord or glands in 
the groin, or with any constitutional disturbance, or derangement of the 
general system. These negative symptoms are very important to be 
noticed for the purposes of diagnosis. There is a swelling, the pecu- 
liarities of which are, that it increases very slowly, is usually of an oval 
form, has a smooth surface, and though somewhat uneven in its general 
outline, has none of the irregular knotted surface peculiar to scirrhus. 
The swelling is not so pyriform as in hydrocele,' but like the testicle 
itself, is compressed laterally. It feels heavy, and not only creates 
inconvenience by its size, but when it becomes large, causes an uneasy 
sensation and dragging pain in the lumbar regions from its weight, 
especially when unsupported. With regard to its fluctuation, it has 
been well remarked, "When the swelling is handled, it communicates 
an impression that it contains a fluid, for it easily yields on pressure ; 
yet there is no true fluctuation, for the tumour does not rise at a distance, 
as it sinks under the pressure of the finger, but it yields only at the spot 
compressed." It is, in fact, more a yielding than a fluctuation. The 
veins of the cord are enlarged. 

By these marks the disease may be distinguished from hydrocele and 
encephaloid cancer, the only two affections with which there is any risk 
of confounding it. 

Anatomical Characters. — The testicle consists of cysts varying much 
in number, size, thickness of their parietes, and nature of their contents. 
At an early stage of the disease there may be only a few, but at an ad- 
vanced period they are almost innumerable ; they are small and vas- 
cular at first, and contain a transparent fluid. As the cysts increase, 
the secreting structure of the testicle becomes atrophied and removed, 
and often wholly destroyed ; the cysts increase in number, thickness, 
and size ; and their contents, instead of remaining transparent, become 
viscid, thick, albuminous, and often present the appearance of a mucous 
secretion. The contents of the cysts present at least as great varieties 
as the size and thickness of the parietes in which they are contained ; 
the latter becoming sometimes exceedingly dense and firm. The tunica 
albuginea and tunica vaginalis become thickened, and the surfaces of the 
latter more or less adherent. 

Treatment.— Castration is the only proceeding attended with any ad- 
vantage, and as the disease is not of a malignant nature, the results of 
that operation are almost invariably satisfactory. In some exceedingly 
rare instances, medullary disease has been found combined with the 
affection ; in such cases an operation is quite unsuitable, inasmuch as it 
cannot save life. 



570 ENCEPHALOID CANCER OF THE TESTIS. 

ENCEPHALOID CANCER OP THE TESTIS. 

This malignant disease, described under the names of soft cancer, 
fungoid disease, fungus nematodes, medullary sarcoma, pulpy testis, 
and encephaloid cancer, is by no means uncommon ; and, although no 
age can be said to be exempt from it, many instances of it being recorded 
even in children and young persons, yet it much more frequently occurs 
between the ages of eighteen and thirty-five, than at any other period 
of life. 

Symptoms. — For the purpose of diagnosis, the peculiarities of the dif- 
ferent symptoms require to be minutely observed. Swelling is the 
earliest symptom : it begins in, and is for some time confined to the 
testicle, and while so confined, is globular, being somewhat of the shape 
of an orange, instead of being compressed laterally, as the testicle in the 
normal state is. It is rather hard at first, pretty uniform in its general 
outline, and entirely destitute of fluctuation. As the disease advances, 
the epididymis becomes involved, and there may occur slight effusion into 
the tunica vaginalis, constituting the condition called by some hydro- 
sarcocele ; and when the disease has advanced thus far, the swelling 
may be less flattened laterally, and present more of the pyriform shape 
of hydrocele. As the disease advances still further, the cord and the 
glands in the groin become affected, and at last firmly adhere to the sur- 
rounding parts. The swelling of the testicle, as has been already stated, 
is at first round and regular; afterwards it becomes uneven, and on ex- 
amination has an elastic feel, which is very deceptive, and, unless ex- 
amined carefully, may be mistaken for fluctuation. If the surgeon be 
induced by the elastic feel to make a puncture, blood only escapes. In 
the early stage of the disease, the integument is free from discoloration, 
and does not adhere to the swelling ; in the next stage it still does not 
adhere, and has a natural appearance, but the veins in it are varicose ; 
and in the third stage the integument is involved, adheres to the tumour, 
and presents a dark livid discoloration ; and if the patient do not very 
soon fall a victim to the disease, the integument at last ulcerates, and 
a fungus, which frequently bleeds, starts up and increases rapidly. It 
is, however, very rare to see this fungus, as the disease generally proves 
fatal by the constitutional symptoms, before it arrives at that stage. I 
once had an opportunity of seeing the disease in that stage in a member 
of the Profession, who was a pupil of my own ; and in that case the 
hemorrhage from the fungus was at times very considerable. The pain 
at first is not constant, but ultimately becomes very severe, and in the 
cases which have come under my own observation, the patients have de- 
scribed the pain as a most distressing feeling of weight, as if a heavy 
body rested on the testicle. ' In some instances the tumour in the loins 
is exceedingly painful ; but in others it gives rise to comparatively little 
uneasiness — a circumstance which Sir Benjamin Brodie supposes to de- 
pend on the fact of the tumour sometimes pressing on the nerves, and 
sometimes being in a measure removed from them. The pain in the 
testicle and in the loins is in some cases most distressing. The extre- 
mity on the affected side becomes swelled and ©edematous : in some in- 
stances the glands in the opposite groin become affected ; and the 
scrotum, glands of the groin, integument, and pubes, all become firmly 



EXCISION OF THE TESTICLE. 571 

adherent to each other, and in a measure all involved in one diseased 
mass. It is very rare for both testicles to become affected, and, singular 
as it is, one testicle is often found to all appearance perfectly sound, 
while the scrotum around it is completely involved in the disease of the 
opposite side. The disease increases very rapidly, the appetite fails, the 
countenance is sallow, the body becomes very rapidly emaciated, and the 
patient falls a victim to the symptoms of cancerous cachexia. 

Such are the principal symptoms of this most distressing and incurable 
disease. Of the present state of our knowledge of the origin, and ana- 
tomical and microscopical characters of encephaloid cancer, an account 
will be given in the section on Carcinoma in the chapter on Tumours. 
The disease is invariably fatal, whether the part be removed or not. No 
treatment has any effect in arresting its progress, and all that the sur- 
geon can accomplish by medicine, and indeed the only course that it is 
proper to pursue, is to alleviate the suffering caused by some of the most 
urgent symptoms. 

SCIRRHUS OF THE TESTICLE.- 

This is a very rare disease, and as yet no case of it has come under 
my observation, either in public or private practice. Sir Astley Cooper 
says he has seen but a few examples, and gives the following description 
of the disease : — " A truly scirrhus affection of the testicle begins in the 
body of it, with an extremely hard swelling, which may immediately 
inform the surgeon of the nature of the disease. It feels like a marble 
body lodged within the scrotum, and it is tuberculated on its surface. 
It sometimes begins in the centre of the testicle, and gradually extends 
until the whole is involved in the disease. The epididymis next becomes 
the seat of the disease, that portion being first attacked which communi- 
cates with the vas deferens. The spermatic cord becomes enlarged, and 
tubercles of various sizes form upon it. After the spermatic cord has 
become enlarged, a hard tumour forms beneath the emulgent artery, 
which may be felt through the abdominal parietes. In true scirrhus the 
testicle does not become enlarged to any considerable size. After the 
swelling in the loins, the thigh becomes enlarged and cedematous on the 
side of the disease, which arises from the obstruction to absorption ; and 
the pressure on the veins may also have influence in producing this effect." 
Prognosis is as unfavourable here as in examples of scirrhus in other 
situations. The common and microscopic characters of fibrous carcinoma 
are described and delineated in the chapter on Tumours. 

EXCISION OF THE TESTICLE. 

The hair having been shaved from the pubes, the patient having been 
brought under the influence of chloroform, and placed in the recumbent 
position, with the thighs separated, the surgeon with his left hand grasps 
the tumour behind, so as to make the integument tense in front, and 
then makes two elliptical incisions, extending from the external aperture 
of the inguinal canal to the under part of the swelling, and embracing 
between them as much integument as it may be necessary to remove 
with the view of preventing redundancy after the operation. Due 
allowance, however, must be made for the integument drawn from sur- 
rounding parts, resiling after removal of the tumour. The cord should 



572 HYDROCELE. 

then be exposed, firmly grasped by an assistant, and cut through as low 
down as may be compatible with the entire removal of the disease. The 
operator takes hold of the under portion of the cord, and with a few 
movements of the knife extirpates the testicle. The vessels of the cord 
having been tied, as well as any other vessels that may be found to 
bleed, the edges of the wound are approximated, dressed according to 
approved principles, and supported by a T bandage. The under part 
of the wound hardly ever heals except by granulation, and on that 
account it can answer no useful purpose to approximate the edges 
closely below. 

HYDROCELE. 

We shall refer to five forms of hydrocele ; namely, three of the tunica 
vaginalis, and two of the cord. The former is named, simple hydrocele 
of the tunica vaginalis testis, congenital hydrocele of the tunica vagi- 
nalis, and encysted hydrocele of the testis ; and the latter, diffuse and 
encysted hydrocele of the cord. 

I. SIMPLE HYDROCELE OF THE TUNICA VAGINALIS TESTIS. 

Symptoms. — There is swelling, which is generally round at first, but 
as it increases it assumes a pyramidal form, with its larger extremity 
downwards, the upper extending as the disease advances, as high as the 
inguinal canal. When the swelling is very large, the upper extremity 
expands considerably, and loses the narrowness of its form. If the 
hydrocele be large, the scrotum, owing to its great distension, loses its 
natural wrinkles, and assumes a glazed appearance ; and in consequence 
of the integuments being drawn upon the tumour, the penis seems con- 
tracted, and the raphe of the scrotum is, as it were, pressed to the oppo- 
site side : the swelling feels much lighter than a tumour of the same size 
caused by disease of the testicle. Besides its form and lightness, the 
swelling has another character which it is of importance to observe, as 
it assists in making out the diagnosis between hydrocele and hernia — it 
commences at the under part of the scrotum, and increases from below 
upwards ; whereas a scrotal hernia commences from above and extends 
downwards. The history of the symptoms thus become useful for 
assisting the diagnosis. 

Fluctuation is usually another symptom of hydrocele, but it is some- 
times not easily perceptible, when the scrotum is very greatly distended ; 
and its absence is not a proof that a tumour is not hydrocele. 

Another symptom is transparency, the presence of which is a sure 
proof of hydrocele. On this subject, Mr. Pott remarks : — " The 
absence of transparency is not a proof that a tumour is not a hydro- 
cele;" and Professor Samuel Cooper observes that — "although the 
absence of transparency is not a proof that a tumour is not a hydro- 
cele, yet its presence is an infallible test that it is." According to Sir 
Astley Cooper, we never fail, on proper examination, to discover trans- 
parency in such hydroceles as are formed in this country ; but in per- 
sons who have had hydrocele formed in warm climates, the parietes of 
the scrotum are sometimes rendered so thick as to be no longer trans- 
parent. Two cases have come under my own observation, in which it 
was impossible to discover any transparency ; the one in private prac- 



HYDROCELE. 



573 



tice, the other in a patient under my care in the Royal Infirmary, Aber- 
deen. In each case the fluid was of a greenish black colour, and very 
grumous ; and to this condition, in both instances, I referred the absence 
of transparency. In the situation of the testicle the tumour is always 
opaque. In common hydrocele another symptom useful for diagnosis 
is, the free state of the cord; in hernia the cord is covered by the 
swelling, but in hydrocele it can be felt free in the inguinal canal. 
Another symptom of a tumour being a hydrocele is, its freedom from 
pain or tenderness under ordinary circumstances, or even on pressure, 
except at the testicle, where there is slight tenderness on pressure ; but 
at other parts there is no tenderness, and beyond inconvenience from 
its bulk and a sense of weight, the swelling gives rise to little or no dis- 
comfort. 

State of the Parts. — The swelling is caused by a fluid which is usually 
transparent, and of an amber, pale yellow, or straw colour, sometimes, 
though rarely, of a greenish or blackish green colour. Sometimes it is 
thick, and of a grumous appearance, and occasionally it contains a quan- 
tity of flaky matter, composed chiefly of albumen ;' and in some instances, 
more especially in old persons, the fluid contains cholesterine in the 
form of minute shining particles. The seat of the fluid is the tunica 
vaginalis, which in most instances is transparent and simply distended ; 
but sometimes it is thickened, and occasionally, in consequence of pre- 
vious adhesions, it presents a sacculated arrangement, constituting what 
is called a multilocular hydrocele. The usual situation of the testicle is 
at the back of the swelling and below its middle, and 
this is the situation in which, from its natural relations, Fig 215. 

it might be expected ; as it is not in the normal condi- 
tion of the parts adherent to the surrounding parietes 
laterally or anteriorly, but only posteriorly : but in some 
cases, in consequence of adhesions having been contracted 
between the tunica vaginalis propria and the tunica vagi- 
nalis reflexa by inflammation previous to the occurrence 
of hydrocele, it is found in the front or in other parts of 
the swelling. It is, of course, of much practical im- 
portance to ascertain the situation of the testicle, that it 
may be avoided in the operation ; the opacity, and the 
tenderness and doughy feel on pressure will indicate its 
position. 

Treatment. — The treatment adopted in all cases, ex- 
cept those of children, is by operation, and that of two 
kinds, palliative and radical ; the former consisting in 
merely drawing off the fluid by tapping, the latter in 
doing this, and also in using means for the purpose of 
inducing such changes as may prevent the return of the 
fluid. 

The radical treatment by injection is that practised at 
the present day. The instruments necessary for this 
proceeding are a round trocar, and a caoutchouc bag 
with a nozzle and stop-cock, or a syringe ; the fluid, port 
wine or a solution of the sulphate of zinc, or a fluid con- 
taining one part of the tincture of iodine and three of 



574 



HYDROCELE. 



water, or a very small quantity of the tincture of iodine alone. The 
patient should be placed erect ; the surgeon should with his left hand 
grasp the tumour behind, so as to render it prominent and tense in 
front, and with his right hand send the trocar and canula through the 
parietes, holding them perpendicular to the surface until penetration be 
effected, and then directing them obliquely upwards, so as to diminish 
the danger of wounding the testicle. The trocar having been withdrawn, 
and the fluid allowed to escape, the injection is thrown into the canula 
by adapting to it the nozzle of the caoutchouc bag, or the syringe'. The 
injection is allowed to remain, until the patient feels pain in the loins 

or testicle, when it is withdrawn. 
Fig. 216. The time for its remaining varies 

in different persons ; in adults it 
is usually from four to seven mi- 
nutes ; but in all cases it is with- 
drawn when the patient begins to 
feel pain in the testicle or along 
the course of the cord. In addi- 
tion to the pain, patients often 
experience a feeling of faintness 
and sickness. The fluid having 
been withdrawn, the patient should 
be put to bed, the testicle sup- 
ported, and the after-treatment 
regulated according to the charac- 
ter of the supervening symptoms. 
If no symptoms of inflammatory 
action present themselves, the pa- 
tient should be induced to move 
about, and be allowed a generous 
diet, and the scrotum should be 
gently compressed and handled so as to occasion friction between the 
surfaces of the tunica vaginalis ; but if the inflammation threaten to be 
excessive, or so great as to render suppuration probable, rest, low diet, 
support of the testis, and the ordinary treatment for acute orchitis, 
should be enjoined. The tumour usually returns very quickly, and 
often requires the size of the hydrocele previous to the tapping ; but in 
the course of twelve or fourteen days, under proper treatment, the parts 
generally resume their usual size. At one time it was supposed that 
injection effected a radical cure by the obliteration of the cavity of the 
tunica vaginalis caused by complete adhesions of the surfaces of that 
membrane ; but it is now known that, although the serous surfaces are 
sometimes united, this state is not essential, that more commonly the 
adhesions are only partial, and that the cure is produced by an altera- 
tion in the secernment function of the membrane. Many different kinds 
of fluid have been used for injection, as dilute spirits of wine, dilute 
port wine, port wine undiluted, solution of alum, solution of the sul- 
phate of zinc, cold water, lime water, and tincture of iodine, either alone 




Fig. 216. From Liston, 



HYDROCELE. 575 

in very small quantity, or mixed with water in the proportion of one 
part to three. Until lately, port wine and the solution of sulphate of 
zinc were the favourite injections, but the tincture of iodine whh water 
is now generally preferred. Mr. Martin, a surgeon in India, was the 
first who tried iodine injections. His proceeding was, to use one part 
of the tincture to three of water, to inject only a very small quantity, 
and to allow it to remain ; and the result of this practice was, that of 
two thousand three hundred and ninety-three cased treated at the native 
hospital of Calcutta, the failures were under one per cent. The use of 
iodine injections has since been tried by surgeons in most parts of the 
world, and, so far as their experience is recorded, with satisfactory 
results. Some use a very small quantity of the tincture alone, and 
allow it to remain. Others, and perhaps a larger number, use the injec- 
tion of the strength employed by Mr. Martin, and allow it to escape. 
My own experience in the use of iodine and water, allowing it to escape, 
has been most satisfactory. 

In children it is not advisable to have recourse to injections ; neither 
is it necessary, as the swelling is in most cases easily dispelled by 
the application of discutient lotions ; and when this treatment is not 
found to produce the desired result, simple puncture with the lancet, and 
escape of the fluid, are usually followed by a radical cure. 

In two other conditions injection is not advisable, namely, when 
the testicle is diseased, and when, though it is sound, the hydrocele is 
very large. In the latter case the most prudent method of proceeding 
is to evacuate the fluid by tapping, to allow its reaccumulation until the 
hydrocele attain a moderate size, and then to proceed with tapping and 
injection. 

Various other methods of treatment have been employed for effecting 
a radical cure, as incision, excision, caustic, seton, and acupuncture ; 
but as these methods have almost all fallen into complete desuetude, it 
is unnecessary to describe them. 

II. CONGENITAL HYDROCELE OF THE TUNICA VAGINALIS. 

This differs from common hydrocele, inasmuch as the fluid communi- 
cates with the cavity of the peritoneum by a vaginal process of that 
membrane, within the inguinal canal. In this variety, injection must 
never be employed while the communication remains, as peritonitis 
might result from the extension of the inflammation to the abdomen. 
The first indication is, to obliterate the tubular communication with the 
abdomen ; and the best means for this purpose is gentle pressure by the 
use of a truss. After the obliteration has been accomplished, the tumour 
is often dispelled in children by the use of discutient lotions, and in 
adults the usual treatment of injection may be employed. The only 
judicious operation in any case before obliteration, is the simple drawing 
off of the fluid. 

III. ENCYSTED HYDROCELE OF THE TESTIS. 

In this form the fluid is contained in a cyst, or cysts, distinct from 
the cavity of the tunica vaginalis. These collections present the three 
following varieties : — first, they occur, and that most frequently, below 



576 HYDROCELE. 

that part of the tunica vaginalis which covers the epididymis ; and the 
cysts differ greatly in size, number, and form, being in some instances 
small and pressed into the epididymis, while in some the tunica 
vaginalis is raised up by them, and they assume a pendulous, peduncu- 
lated form, and in others they become large, but remain connected with 
the epididymis by a broad base ; secondly, they occur between the tunica 
albuginea and the tunica vaginalis testis ; in this, which is the rarest 
form of all, the cyst is usually single and of small size ; and thirdly, 
between the layers of the loose or outer portion of the tunica vaginalis. 
In encysted hydrocele the tumour should not be interfered with, un- 
less it become troublesome from pain, or inconvenient from its size. 
When interference is deemed advisable, the most judicious proceeding 
is merely to draw off the fluid by simple puncture. If the tumour should 
return, and it be thought advisable to endeavour to effect a permanent 
cure, as the treatment by injection has not been found to succeed so 
well as in common hydrocele, the preferable treatment, especially when 
there is a number of cysts, is the use of a seton, which should be intro- 
duced and retained until consolidation be effected. 

HYDROCELE OF THE CORD. 

Of this affection there are, as has been already stated, two varieties, 
namely, diffuse and encysted. 

I. DIFFUSE HYDROCELE OF THE SPERMATIC CORD. 

This exceedingly rare variety consists of an albuminous fluid of a 
white or yellowish colour, diffused throughout the cellular tissue con- 
necting the vessels of the spermatic cord, which tissue is surrounded by 
a cellular sheath, and this sheath, again, is invested by an expansion of 
the cremaster muscle and the coverings of the cord external to it. The 
affection is of the nature of simple oedema ; the cells, however, are so 
greatly distended as to be converted into large vesicles. In some in- 
stances, at the lower part of the tumour, the cells disappear, and the 
fluid at that part is contained in a single cavity, where it forms a swell- 
ing attended with fluctuation. An example of this rare form of hydro- 
cele has not come under my own observation. Mr. Pott, who appears 
to have met with more examples of it than any other surgeon, gives the 
following description of its symptoms and appearances : — " In general, 
while it is of moderate size, the state of it is as follows : The scrotal bag 
is free from all appearance of disease ; except that when the skin is not 
corrugated, it seems rather fuller, and hangs rather lower on that side 
than on the other, and if suspended lightly in the palm of the hand, feels 
heavier ; the testicle, with its epididymis, is to be felt perfectly distinct 
below this fulness, neither enlarged nor in any manner altered from its 
natural state ; the spermatic process is considerably larger than it ought 
to be, and feels like a varix, or like an omental hernia, according to the 
different size of the tumour ; it has a pyramidal kind of form, broader 
at the bottom than at the top ; by gentle and continued pressure it 
seems gradually to recede or go up, but drops down again immediately 
on removing the pressure, and that as freely in a supine as in an erect 
posture ; it is attended with a very small degree of pain or uneasiness, 



HYDROCELE. 577 

which uneasiness is not felt in the scrotum, where the tumefaction is, 
but in the loins. If the extravasation be confined to what is called the 
spermatic process, the opening in the tendon of the abdominal muscle is 
not at all dilated, and the process passing through it may be very dis- 
tinctly felt ; but if the cellular membrane, which invests the spermatic 
vessels within the abdomen, be affected, the tendinous aperture is en- 
larged, and the increased size of the distended membrane passing through 
it produces to the touch a sensation not very unlike that of an omental 
hernia." 

Treatment. — While the swelling is small and unattended with particu- 
lar inconvenience, the most judicious course is not to interfere with it. 
When interference becomes necessary, the best mode of treatment is 
acupuncture. The punctures are made at the under part of the swell- 
ing, and need not be numerous. The fluid escapes into the cellular tis- 
sue of the scrotum, and is soon removed by absorption. This mode of 
treatment is unattended with danger, whereas free direct incision into 
the cells is not so. 

II. ENCYSTED HYDROCELE OF THE SPERMATIC CORD. 

The symptoms of this variety are a swelling, slow in its growth and 
painless, usually of an oval form, movable on the cord, attended with 
fluctuation, and in most instances, distinctly transparent. The tumour 
is generally circumscribed, and the testis can be felt separate. This 
affection is most common in infants, but it is met with at all periods of 
life. The fluid is sometimes of a straw colour, but more frequently 
limpid, and contains little or no albumen. Occasionally more cysts 
than one are found ; but this is unusual, the fluid being generally con- 
tained in a single cyst. This cyst is in most cases formed of an ob- 
literated portion of the vaginal process of peritoneum drawn down at 
the period of the descent of the testicle ; sometimes however the cyst is 
an adventitious formation. It is embedded in the cellular tissue con- 
necting the vessels of the cord with each other, and is embraced by the 
other coverings of the cord. 

In children, this affection usually disappears under the use of appli- 
cations calculated to promote absorption, as in simple hydrocele at the 
same period of life ; and in adults, if interference be necessary, the 
cure may be accomplished either by tapping and injection, or by the 
use of a seton. 



37 



578 



CHAPTEE XVII. 

AFFECTIONS OF GENITO-URINARY ORGANS. 

GONORRHOEA. 

The essential and characteristic symptom of gonorrhoea is a purulent, 
or muco-purulent discharge from the urethra of the male, or the vagina 
of the female. 

It may be either simple or virulent in its nature. In the former case, 
it is caused by sympathetic irritation, such as teething ; or it is but a 
symptom of the existence of other affections, generally of rheumatism 
or gout. In the latter, it depends upon the direct application of a 
specific irritant, occurring usually during sexual intercourse. 

When it assumes a chronic form, it is called gleet, and often resists 
most obstinately, for months or even longer, every effort for its removal. 

Besides these varieties, the term spurious or external gonorrhoea has 
been given to a discharge of the same nature from the surface of the 
glans, or the lining membrane of the prepuce ; some authors term it 
balanitis. 

SIMPLE GONORRHOEA. 

If it arises from simple local or constitutional irritation, such as 
teething, the use of bougies, violent horse-exercise, a blow on the peri- 
neum, &c, the only symptom will be a purulent discharge of a whitish 
colour from the urethra, for the most part unaccompanied with heat, 
pain, or ardor urinse; but if it is a precursory symptom of gout or 
rheumatism, in which case it is called arthritic gonorrhoea, the presence 
of symptoms of local inflammation and of ardor urinse will render the 
diagnosis between it and virulent gonorrhoea extremely difficult. The 
discharge, which in the case of gout is supposed to arise from a super- 
abundance of uric acid in the urine, will disappear immediately upon 
the development of the disease itself. 

In this affection scarcely any special treatment is required, the re- 
moval of the cause of irritation being generally quite sufficient ; but if 
necessary, recourse may be had to mild injections, laxatives, and such 
remedies as the state of the body may indicate. 

Sir Astley Cooper has in his lectures strongly pointed out the im- 
portance, in a medico-legal point of view, of distinguishing accurately 
between this and the venereal or virulent form of the disease, especially 
in cases where it is asserted that a rape has been committed on very 
young children ; the only ground of such accusations often being the 



GONORRH(EA. 579 

existence of a discharge from the vagina of the child. The possibility, 
therefore, of this being of a harmless nature, and not the consequence 
of sexual intercourse, must always be kept in mind. 

VIRULENT, OR VENEREAL GONORRHOEA. 

Cause. — This form of gonorrhoea is produced by the application of a 
specific irritant or virus to the surface of the mucous membrane of the 
urethra or of the vagina ; such application occurring usually, but not 
necessarily, during sexual intercourse. 

Nature of the Virus. — This virus is essentially distinct from that of 
syphilis. The experiments of John Hunter seem, indeed, to disprove 
this ; but they have since been carefully repeated by Benj. Bell and 
others with an entirely opposite result ; and M. Ricord of Paris has 
completely set this question at rest by his numerous and well-conducted 
researches. 1 Out of five hundred and forty-nine cases, occurring in his 
male and female wards, of gonorrhoea uncomplicated with chancre, and 
one hundred and twelve cases of chronic gonorrhoea or gleet, all of which 
were subjected to a test of inoculation in other parts of the body, not 
one produced the characteristic pustule which he invariably found to 
result from inoculation with matter from chancre in any of its forms 
during the period of infection. The circumstance of gonorrhceal matter 
having by inoculation produced chancres in. the experiments of Hunter 
and others, M. Ricord attributes to the presence of concealed chancres 
(chancres larves) in the urethra, which he has shown to be a frequent 
complication. It is right, however, to state that the late Mr. Carmi- 
chael, of Dublin, continued to adhere to the opinion, that gonorrhoea 
virulenta produces the same constitutional effects, and is therefore iden- 
tical in its nature with that mild form of chancre which precedes the 
papular eruption. But in his lectures, 2 whilst treating upon this subject, 
he has not taken into consideration the possibility of the existence of 
concealed chancres, which M. Ricord has pointed out in every one of the 
five cases quoted by Carmichael in support of his own theory, and which, 
if acknowledged, would reconcile his view with that generally received, 
namely, that the gonorrhceal virus is essentially distinct in its nature 
and effects from that of syphilis. 

Period of Development. — The time at which the discharge first makes 
its appearance varies, but is generally from the fourth to the seventh day 
after infection. Occasionally it shows itself earlier, even in twenty-four 
hours, of which Sir A. Cooper mentions an instance ; sometimes after a 
much longer period. In this latter case, however, it is often retarded 
by the co-existence of the premonitory symptoms of another disease, 
such as fever, on the recession of which disease it may immediately ap- 
pear. 

Its duration is very variable, and cannot be predicted from either the 
nature or the severity of the symptoms. It often runs its whole course 

1 "In the Lock Hospital of Edinburgh, Ricord's experiments have lately been repeated 
in a number of instances •with nearly similar results." — Sir George Ballingall's Military 
Surgery, p. 425. 

2 Clinical Lectures on the Venereal Disease, by R. Carmichael, 1842. 



580 GONORRHOEA. 

in a few weeks ; at other times it lingers on for months, or even years, 
constituting what is termed gleet. 

The following additional facts respecting gonorrhoeal infection appear 
to be well established. 1. The disease is not communicable, by sexual 
intercourse before the discharge appears. 2. After the discharge is es- 
tablished, if the urethra be previously washed out by means of a syringe, 
it is not probable that the disease will be communicated. 3. The matter 
possesses the power of infection for an indefinite period ; Titley records 
the case of a girl'communicating the disease on the first night after her 
leaving the Magdalene, where she had been for twelve months. 4. Two 
people having gleet may have intercourse with impunity ; but either of 
them will communicate gonorrhoea to a sound person. 5. The violence 
of the symptoms depends much upon the habit of body, the scrofulous 
diathesis greatly increasing their severity ; — thus the same woman may 
give a very mild form of the disease to one man, and a most severe form 
to another. 6. The first attack of the disease is always the most violent. 
7. The disease is now much milder than formerly. 

Symptoms. — At first there is merely a slight uneasiness and swelling 
along the anterior and under portion of the penis, with a tickling, 
teasing sensation over the glans and anterior portion of the urethra, 
the lips of which are found to be slightly red and turgid. Upon 
squeezing the glans a small quantity of a whitish muco-purulent matter 
exudes. 

In a few days, the time varying according to the irritability of the 
constitution, the uneasy tickling sensation gives place to pain, which is 
often remarkably severe. There is an abundant discharge of yellowish 
pus, with scalding pains (ardor urinse) during micturition, the calls to 
which are very frequent. The urethra, in consequence of the inflamed 
state of the mucous membrane, is much narrowed, causing the urine to 
be voided in a stream much smaller than usual, and sometimes forked, 
by reason of bands of lymph stretching across the interior of the canal. 
There may also be painful erections during the night. The pain pro- 
gressively increases, and the matter discharged becomes greenish, or 
perhaps mixed with blood ; and besides the painful erections, chordee 
may now supervene. This term is given to a distorted condition of the 
penis, in which it is curved downwards, or to one side during erection, 
owing to the circumstance that inflammatory effusion into the corpus 
spongiosum prevents equal expansion with the corpora cavernosa. The 
inflammation may extend externally over the glans and membrane lining 
the prepuce, causing effusion into the cellular tissue between it and the 
integument, narrowing the external orifice, and giving rise to phymosis ; 
or, if the prepuce had been previously retracted, to paraphymosis. 

This is the general progress of a moderately severe attack of gonor- 
rhoea. In some cases, however, the inflammation extends along the 
course of the lymphatics to the inguinal glands, there causing bubo ; or 
backwards along the urethra to the membranous or prostatic portions, 
the neck of the bladder, or the bladder itself. The testicle may like- 
wise become involved. Each of these complications will, however, 
require a separate notice. 

Treatment. — The progress of gonorrhoea may be divided into three 



GONORRHCEA. 581 

stages — the inflammatory, the suppurative, and the chronic ; in each of 
which an entirely different mode of treatment is indicated. Some short 
time, however, generally intervenes between the first appearances of the 
gonorrhoea! discharge and the accession of the inflammatory stage ; 
and it has been recommended, upon high authority, to take advantage 
of this interval and check the disease at once, by throwing into the 
urethra strong injections of the nitrate of silver — ten grains to an 
ounce of water. This plan, however, is no doubt attended with con- 
siderable risk, as it may excite high inflammation of the urethra ex- 
tending perhaps to the bladder. Dr. Titley and Mr. Carmichael agree 
in strongly deprecating the practice ; Ricord, Arnott, and many others, 
strongly recommend it. It is called the ectrotic or abortive treatment, 
to distinguish it from the curative ; and the time for its employment is 
limited to the nascent period of the inflammation, — the object aimed at 
being to prevent the development of the disease. 

Dr. Arnott's mode of employing this treatment is as follows : — About 
a couple of drachms of a solution of the nitrate of .silver, in the propor- 
tion of twelve grains of the salt to an ounce of water, is thrown into 
the urethra by means of a glass syringe ; the penis being at the same 
time elevated and compressed about two inches from the orifice, thus 
insuring complete application of the solution to the urethral membrane 
within this range, and no further. The solution is retained within the 
urethra for not less than half a minute, and no urine is to be passed for 
half an hour after the injection. The immediate visible effect of the 
application is the formation of a coagulated film on the surface of the 
urethral membrane ; and the diminution of pain which the patient ex- 
periences during micturition is probably to be attributed to the protec- 
tion thus afforded to the abnormally sensitive membrane. It is also 
thought that the effects of the application may be partly attributed to 
the well-known action of the nitrate of silver in subduing crescent in- 
flammation. Dr. Arnott thinks that this proceeding is open to only one 
objection, namely, that the period of its applicability is limited to a 
stage of the disease which usually excites but little attention. 

Ricord, while he advocates the adoption of the abortive treatment, 
admits, as the result of his own experience, that although it has many 
advantages, it has its drawbacks and unpleasant consequences. He 
recommends that the urethra should not be compressed during the injec- 
tion, and that the abortive treatment should also include the internal 
use of copaiba and cubebs in large doses. Injections modify and create 
a new action in the mucous membrane, and copaiba and cubebs, by 
yielding their principle to the urine, contribute powerfully to render 
that modification more effective. In the female syphilitic ward of the 
Royal Infirmary of Aberdeen, I have not ,had opportunities of trying 
the effect of ectrotic "treatment, because the period for its employment 
is over before patients present themselves for admission : and my oppor- 
tunities of forming an opinion from personal observation in males in 
private practice have been too few to enable me to arrive at a decided 
conclusion : but in the very limited number of cases in which I have 
employed it, I adopted Dr. Arnott's method, and had every reason to 
be satisfied with the results. 



582 GONORRH(EA. 

If the disease remain and progress after one, or at most two injec- 
tions, the continuance of this treatment must be deemed unadvisable. 

With regard to curative treatment, an entirely different mode is indi- 
cated in each stage. 

I. Inflammatory Stage. — A suspensory bandage should be used from 
the commencement. Rest, attention to cleanliness about the parts, low 
diet, abstinence from all stimulating drinks, with the use of antimonials 
in nauseatory doses, must be strictly enforced. If the inflammatory 
symptoms run extremely high, with much constitutional disturbance, it 
may be necessary to have recourse to local depletion, and that very 
freely, a dozen or twenty leeches being applied to the perineum or groin. 
It would not be advisable to apply them to the penis itself: for if the 
gonorrhoea should be complicated with concealed chancres, the leech- 
bites would become infected, and the disease be considerably aggravated. 
Phymosis might also be the result of such an application, from infiltra- 
tion of the cellular tissue. The patient should drink largely of diluents, 
such as barley-water, linseed tea, solution of gum arabic, &c. ; these 
tend to diminish the irritating quality of the urine, and thus modify 
some of the distressing symptoms. To mitigate the ardor urinse, if very 
severe, about twenty drops of liquor potassas with thirty drops of tinc- 
ture of hyoscyamus, or five grains of ext. conii, may be given in cam- 
phor mixture, three or four times a day, with much benefit ; emollient 
fomentations being at the same time applied to the penis. If painful 
erections or chordee supervene, a most efficient remedy is camphor with 
opium, which may be given in the form of pills at bed-time. During 
the attacks, cold should be applied to the penis and the feet. The 
paroxysm is often checked by the patient getting out of bed, and put- 
ting his feet upon the cold floor ; but if these means do not succeed, an 
opiate enema should be given, or a grain or two of solid opium intro- 
duced within the rectum. The bowels must be kept moderately open, 
by means of saline purgatives ; but smart purging is to be avoided, 
because irritation of the rectum increases the pain of the urethra. 

By these means the inflammatory symptoms, even if of considerable 
severity, may be subdued ; but in most cases, such active treatment is 
unnecessary. The inflammation is generally slight, and in a few days 
gives way to rest, cleanliness, low diet, the free use of antimonials, 
liquor potassse, demulcent drinks, with fomentations and support of the 
parts. The treatment must then be altered, and such remedies adopted 
as act favourably upon the inflamed mucous membrane. 

II. Suppurative Stage.— The inflammatory symptoms being much 
checked, and the discharge having assumed a purulent character, even 
if considerable ardor urinae be still present, the use of copaiba or cubebs 
should be commenced, the antiphlogistic regimen and rest being at the 
same time strictly enforced. 

These medicines seem, by the principle they yield to the urine, to 
exert a favourable action upon the urethra itself; since, when the seat 
of gonorrhoea is the glans, vagina, or vulva, they appear to be of no ser- 
vice. The balsam of copaiba may be given alone, or on sugar, or float- 
ing on water, in doses of about thirty-five drops three times a day ; but, 
as it is then apt to excite nausea, and other disagreeable symptoms, it 



GONORRHOEA. 583 

is better to give it in the form of emulsion, combined if necessary with 
diuretics. The following is a useful formula for its administration, — a 
wine-glassful being given night and morning. 

R Bals. Copaibse 3vj. 

Mucilag. Acacise ..... 3vj. 

Spir. JEth. Nitrosi . . . . 3ij. 

Sacchari Albi gss. 

Aquae Cinnamomi 3yj. 

Fiat Mistura. 

Another very convenient form of its administration is in pills, made 
by mixing the balsam with one-sixteenth part of its weight of calcined 
magnesia. Dr. Titley strongly recommends Morson's soluble extract 
of copaiba, one drachm of which, dissolved in eight ounces of boiling 
water and strained, forms an agreeable mixture, and is one of the best 
forms of exhibiting this medicine. The gelatinous capsules, although 
they answer the purpose of introducing the balsam into the stomach 
without being tasted, do not prevent the consequent nausea, and the 
purity of the copaiba cannot be relied on when disguised in this way. 

Cubebs when fresh ground and pure are undoubtedly of great service 
in this disease. They may be given two or three times a day in water 
or milk, in doses of half-a-drachm, increased afterwards to one or two 
drachms, a grain or two of nitrate of potass being often added advan- 
tageously. If the discharge is not suppressed in eight or ten days, the 
cubebs will have no effect, and may be discontinued. In successful 
cases the beneficial results generally appear in two or three days, and 
may be known by the discharge first assuming a ropy character, and 
then ceasing altogether. 

Injections. — A considerable number of days must be allowed to elapse 
after the subsidence of the inflammatory symptoms, before injections can 
properly be used ; then, however, they are often of the greatest service. 
Those most in use are, solutions of the diacetate of lead, sulphate of 
zinc, and nitrate of silver ; the last is the most efficient, but must be 
used very cautiously at first, commencing with a quarter of a grain to 
an ounce of water, and gradually increasing it to one or even two grains. 
The diacetate of lead, and sulphate of zinc may be used as strong as 
two grains to the ounce from the very commencement, their strength 
being gradually increased, if necessary. These injections should be 
used two or three times a day ; if, however, they cause pain, they must 
be diluted ; and if the discharge should stop suddenly, or irritation of 
the urethra be excited by their use, they must be altogether discontinued. 

By persevering in the use of these remedies, the gonorrhoea in most 
cases gradually disappears. To prevent its return, the injections must 
be still used for some days, though with less frequency, and of diminished 
strength, and after that time they may be entirely discontinued. 

In some instances, however, the discharge still continues, assuming 
a chronic form, 'and constituting gleet. 

III. Chronic stage or gleet. — All inflammation has now disappeared, 
but the discharge continues, accompanied perhaps with slight ardor 
uringe ; or if it ceases for a few days, it returns again and again without 
any apparent cause. This state may depend upon relaxation, or per- 
haps upon the presence of stricture. If the latter be detected, it must 



584 GONORRHEA IN WOMEN. 

be treated accordingly. In this stage the use of injections must be con- 
tinued, their strength being increased, if necessary ; and if they are 
frequently changed, the desired effect is so much the more likely to be 
produced. 

M. Bicord strongly recommends an injection of a solution of iodide of 
iron, commencing with one grain to an ounce of water, and increasing 
it gradually till it has some effect upon the discharge. This remedy I 
have found very useful. Generous diet, and cold ablutions are also 
useful in this stage ; but perhaps the best treatment is to pass a bougie 
several times a day, following up its use by that of stimulating injec- 
tions. This proceeding at first increases the discharge, but its quality 
is speedily altered, and at length it ceases altogether. The least irrita- 
tion or irregularity of life, is, however, very apt to induce its return. 

Cantharides, taken internally, in the form of tincture, are often of 
great service, and may be given in doses of fifteen or twenty drops, 
twice or thrice a day. This dose should be increased until pain and 
slight strangury be excited in the urethra and neighbourhood of the 
pubes. The discharge will then be found to have assumed a purulent 
character, and will gradually subside as the medicine is discontinued. 

GONORRHOEA IN WOMEN. 

If the discharge proceed from the urethra, the same plan of treat- 
ment must be pursued as in the gonorrhoea of males ; but its seat is 
usually the vulva and vagina, often indeed involving the cervix uteri. 
Out of seventy-two patients in the Female Lock Ward in the Aberdeen 
Royal Infirmary, only three had the urethra affected. 

The symptoms are, inflammation and tumefaction of the parts, with 
pain and scalding at the times of micturition, the latter symptoms 
appearing most distinctly when the urethra is the seat of the disease : 
the discharge stains the patient's linen of a greenish yellow colour, and 
is often very abundant. Upon examination with the speculum, super- 
ficial excoriations are often perceived upon the cervix uteri, or within 
the vagina, and sometimes infiltration takes place to a considerable 
extent into the cellular tissue of the labia and surrounding parts, causing 
great oedema, and occasionally abscess and sloughing in these situations. 

If a case come under treatment before the commencement of the 
inflammatory stage, the urethra not being involved, it may be checked 
at once by injecting a strong solution of nitrate of silver (ten grains to 
an ounce) ; but as this is seldom the case, the antiphlogistic treatment 
must be employed until the inflammatory symptoms have subsided, 
warm emollient fomentations and injections being also used if the pain 
is severe. Should abscess of the labia or external parts ensue, the 
matter must be evacuated as speedily as possible by a large opening. 
As soon as the inflammation is subdued, astringent and stimulating 
injections should be employed. The decoction of oak bark or galls, 
solutions of sulphate of zinc or alum of considerable strength, are of 
great service ; but perhaps the best is a solution of nitrate of silver, two 
or three grains to the ounce : the solution should be injected frequently ; 
or, which will be found still more efficacious, the vagina should be 
plugged with lint dipped in it, and changed two or three times a day. 
This plan, recommended by both Ricord and Carmichael, seldom fails 



COMPLICATIONS OF GONORRHOEA. 585 

to check the discharge very shortly ; it seems to answer two purposes, 
both acting as a local astringent, and separating the parietes of the 
vagina, thus removing a constant source of irritation to the sound parts, 
and insulating the diseased portions. It often happens, however, that 
notwithstanding these applications, the discharge still continues. In 
this case the speculum should be used, and the os uteri examined, as it 
is often found that excoriations or ulcerations exist at this part, and by 
their constant irritation keep up the discharge. If such be discovered, 
they should be cauterized with a pencil of nitrate of silver, which M. 
Ricord recommends also to be gently carried over the vagina itself. 
This plan will seldom be found to fail. 

EXTERNAL, OR SPURIOUS GONORRHEA. 

Balanitis of some authors, Gonorrhoea Prcepulialis of others. 

These terms are used when the gonorrhoea proceeds only from the 
glans penis, or from the lining membrane of the prepuce. 

Rest, moderate diet, and cleanliness, are often sufficient of themselves 
to remove this affection ; if not, and if no phymosis exist, the prepuce 
should be drawn back and the parts gently cauterised with a pencil of 
nitrate of silver, this being repeated every two or three days till the 
cure is effected. If, however, phymosis be present, accompanied with 
considerable inflammation, leeches applied to the groin, and emollient 
fomentations to the affected part will be necessary ; and as soon as the 
inflammation has been subdued, the proper operation must be performed 
for removing the phymosis, as it tends to keep up the discharge by con- 
stant irritation. Should any treatment be necessary after this, the 
gentle cauterising of the part as above directed, or the application of a 
strong solution of nitrate of silver between the glans and the prepuce 
will check the discharge. 

Copaiba and cubebs seem to have no influence on this form of gonor- 
rhoea. 

INFLAMMATION OF THE MEMBRANOUS PORTION OF THE URETHRA. 

Inflammation of the membranous portion of the urethra is often the 
consequence of an attack of gonorrhoea. When this occurs, the symp- 
toms become more marked, especially the ardor urinas ; the whole penis 
is much swollen ; the patient is exceedingly distressed with chordee ; the 
discharge becomes fetid, sometimes tinged with blood ; any pressure 
upon the membranous portion of the urethra causes pain to be felt as far 
back as the anus ; the testicle is usually tender, and sometimes swollen. 

Local bleeding, the application of poultices and fomentations to the 
perineum, and, general bleeding, if requisite, constitute the treatment 
to be employed ; and, if matter form, a free vent must be given to it 
externally, as soon as its presence is detected. 

INFLAMMATION OF THE PROSTATE GLAND. 

The gonorrhoeal inflammation may extend to the prostate gland. This 
is marked by the cessation of the gonorrhoeal discharge, by pain and a 
sensation of weight at the neck of the bladder, with continual irritation 
and desire to pass water, tenesmus, weight and uneasiness in the peri- 



586 INFLAMMATION OF THE BLADDER. 

neum, and tenderness of the gland itself, discoverable on examination 
through the rectum. 

If the attack be violent, complete retention of urine will ensue, with 
great pain from pressure of the contents of the bladder upon the inflamed 
gland. Not unfrequently abscess is formed, the symptoms of which are 
at first very obscure, slight hardness and fulness of the perineum being 
often the only indication of its presence; and it bursts sometimes 
internally into the urethra, or into the rectum, but more frequently 
externally. 

The constitutional symptoms are those of severe inflammatory fever ; 
rigors generally supervening when abscess occurs. 

Treatment. — Local depletion by means of leeches; and general 
depletion also, if the inflammation run high, must be employed ; the 
bowels must be kept open to prevent irritation from the accumulation of 
faeces ; and if there be much fever, antimonials should be given. Sir B. 
Brodie recommends calomel, given so as to affect the system slightly. 
To relieve the pain a warm bath is of great service, and opium may be 
administered per anum in the form of enema ; and the urine, if retention 
takes place, must be drawn off by the gentle introduction of a small 
catheter. 

If, in spite of every effort, suppuration ensue, fomentations and poul- 
tices must be applied to the perineum, and the matter evacuated by 
plunging a bistoury deep through the intervening structures, immedi- 
ately on the detection of fluctuation in the perineum. 

Sometimes, however, the abscess bursts into the urethra ; the patient 
must then be confined to the horizontal position ; and to prevent infil- 
tration or its consequences, a small flexible gum-catheter should be re- 
tained in the urethra for some days ; or a silver one gently introduced 
whenever he desires to void his urine. 

As this usually occurs in scrofulous habits, and often uncomplicated 
with gonorrhoea, the general health must likewise be improved by the 
administration of tonics and generous diet. 

INFLAMMATION OF THE BLADDER. 

When inflammation has extended to the bladder, its mucous membrane 
becomes inflamed, the gonorrhoeal discharge ceases, the desire to make 
water is incessant, the irritation of the mucous coat causes a sensation 
of fulness even when the bladder is empty, and gives rise to constant 
straining to effect its evacuation. The pain, however, is most intense 
when the bladder is distended, and a diagnostic mark is thus established 
between this affection and calculus. The urine deposits a sediment of a 
mucous, purulent, or muco-purulent character. Pain and tenderness 
are felt in the hypogastric region, and symptoms of considerable irrita- 
tive fever. 

Treatment. — This consists of perfect rest in the recumbent posture, 
general depletion if the symptoms be extremely severe, the application 
of leeches to the hypogastrium, the use of hip baths and warm fomenta- 
tions, and the administration of gentle laxatives, with opiate enemata to 
relieve pain. If the urine is acid, saline medicines should be given, and 
calomel combined with opium several times daily ; if alkaline, Sir B. 



INFLAMMATION OF THE BLADDER. 587 

Brodie recommends fifteen or twenty drops of the vinum colchici three 
or four times a day. Should the inflammation depend upon a metasta- 
sis of the gonorrhoea, it will most probably cease on the return of the 
urethral discharge, which should, therefore, be promoted by warm 
emollient fomentations and the hip bath. 

CHRONIC INFLAMMATION OP THE BLADDER, OR CATARRHUS VESICA. 

Constant desire to pass water, caused by irritation of the mucous 
membrane, constitutes at first the principal symptom of this affection. 
After it has existed for some time, the urine becomes loaded with a 
grayish, ropy, tenacious mucus, sometimes tinged with blood, giving a 
highly alkaline reaction, and forming a glairy deposit on cooling, often 
nearly equal in quantity to the urine itself, which is much darker than 
natural, and emits an offensive ammoniacal odour. Sometimes also 
streaks of phosphate of lime are deposited with the sediment. This 
chronic state of inflammation is rarely a primary disease, being generally 
a consequence of calculus, stricture, or enlarged prostate disease of the 
rectum. 

Treatment. — <The exciting cause must be removed or modified, before 
a cure can be effected. Rest in the recumbent posture should be pre- 
scribed, with the pelvis raised, and opium administered, either by the 
mouth or as an enema, to relieve pain, together with gentle laxatives. 
Bleeding, either local or general, unless the inflammation runs very 
high, seems only to aggravate the symptoms by reducing the patient's 
strength, and mercurials are, for the most part, worse than useless. 
Counter-irritation on the hypogastric region in general affords relief. 

Buchu and mineral acids are often useful. The uva ursi and pareira 
brava have been strongly recommended in this disease, the latter espe- 
cially, by Sir B. Brodie, in the form of decoction, made by boiling half 
an ounce of the root in three pints of water down to one pint, and given 
in doses of eight or twelve ounces daily, with the addition of small doses 
of tincture of hyoscyamus and of the mineral acids, if a disposition to 
deposit phosphates exist. Copaiba, cubebs, and the muriated tincture 
of iron, have often a beneficial effect when given in small doses ; and 
when the inflammation has greatly abated. As the cure progresses, it 
has sometimes been found advantageous to use simple injections of tepid 
water, slightly acidulated by the addition of ten drops of the diluted 
nitric acid to two ounces of warm water. If, however, pain or irritation 
be excited by their use, they must be at once discontinued. The bene- 
ficial effects of this proceeding have always appeared to me to be tem- 
porary. The best means for washing out the bladder, is a double 
catheter with a syringe adapted to one of the orifices. Rest, the recum- 
bent posture, with the pelvis raised, opiate enemata, counter-irritation 
on the hypogastrium by means of the nitrate of silver, pareira with the 
mineral acids and tincture of hyoscyamus, the regulation of the bowels 
by small doses of castor oil, and a regimen rather generous than other- 
wise, are the remedies most generally useful. 

[Injecting the bladder with a solution of nitrate of silver, will be 
found to be attended with the same beneficial results which follow its 
application in other diseased mucous membranes, and the injection of a 



588 



PHYMOSIS AND P AR APH YM SIS. 



solution of the sulphate of morphia, when the pain is distressing, pro- 
duces great relief. — Ed.] 

WARTS. 

Preputial gonorrhoea frequently gives rise to warts, the position of 
which may be any part of the surface of the glans and prepuce. They 
vary much in size and number, being sometimes few and small, some- 
times large and covering the whole of the parts. If few and small, they 
soon disappear under the repeated application of the sulphate of copper ; 
but if large, the preferable proceeding is removal by scissors, followed 
by occasional application of the sulphate of copper. 

PHYMOSIS AND PARAPHYMOSIS. 

In most instances the prepuce can be easily retracted over the glans 
even during erection ; in some cases, however, this is impracticable, and 
such a stage is termed phymosis. 

It may be either congenital or accidental. In the latter case it is 
often produced by inflammation, and consequent swelling of the prepuce 
from an attack of gonorrhoea, by the cicatrisation of uloers, the presence 
of warts, &c. 

When the phymosis exists only in a slight degree, no great inconve- 
nience is felt, nor is any special treatment requisite ; but when it occurs 
to a greater extent, the matter secreted collects beneath the prepuce, 
giving rise to considerable irritation, and to a discharge, resembling 
gleet, which often excites ulceration. If the orifice is very much con- 
tracted, much pain and suffering are experienced in passing water. If 
inflammation arise, the prepuce becomes enormously distended, and by 
its mechanical pressure frequently causes great pain. 

When inflammation occurs, the most active antiphlogistic remedies 
must be adopted. Fomentations and poultices must be applied, and 



Fig. 21; 



Fig. 218. 





suspension of the part resorted to, together with antiphlogistic treat- 
ment ; and should the inflammation still continue unchecked, or reten- 
tion of the urine take place, or should the phymosis depend on warts, 
on obstinate or irritable sores, or on an ulcerated condition of the sur- 



Figs. 217, 218. From Liston. 



PERMANENT STRICTURE. 589 

faces of the prepuce and glans, the prepuce must be slit up by an opera- 
tion. This is effected by inserting a director by the side of the frsenum, 
introducing a sharp-pointed bistoury upon it, transfixing the prepuce 
and slitting it up, one or two small sutures being then passed through 
the edges of the wound to prevent the separation of the internal and 
external integuments. The unseemly appearance of the flaps is soon 
almost entirely removed by interstitial absorption. If the phymosis de- 
pend upon too great length of the prepuce, which not unfrequently 
happens, especially when it is congenital, this may be drawn forwards 
from the extremity of the glans, and a portion of it removed by a cir- 
cular incision — the same precaution being afterwards taken to secure the 
adhesion of the integuments and lining membranes by slight sutures. 

An opposite condition of the prepuce often exists, where, having been 
drawn back over the glans, it is incapable of being returned. This is 
called paraphimosis. 

The cause of this is in almost every instance a partial phymosis. 
When it assumes this condition, it acts as a tight ligature, constricting 
the urethra and impeding the return of the blood from the glans, which 
in consequence becomes cedematous and inflamed, and, unless the stran- 
gulation is quickly relieved, gangrene ensues. 

When the constriction is only slight, it will yield to the local applica- 
tion of cold and manipulation of the same nature as the taxis ; but if 
this fail, the constriction must be divided ; and this is best effected by 
depressing the penis, separating the swellings behind and before the 
constriction, and with a sharp-pointed curved bistoury dividing the stric- 
ture. The symptoms will be at once relieved, although it may not be 
practicable to return the prepuce immediately after the operation. 

PERMANENT STRICTURE. 

Exciting Causes. — I have included stricture under the head of con- 
sequences of gonorrhoea, as this is one of the most frequent exciting 
causes. It may, however, arise from any source of urethral irritation, 
such as mechanical injury, the use of injections of too stimulating a 
character, calculus in the bladder, the presence of lithic acid or of phos- 
phatic deposit in the urine, or contraction consequent on ulceration of 
the urethra, however such ulceration may have been induced. 

Seat of Stricture. — Stricture may occur at any situation anterior to 
the prostatic division of the urethra ; but its most frequent sites are at 
the bulb, at the natural bend of the penis when pendulous, in the mem- 
branous portion of the urethra, an inch behind the orifice itself, consti- 
tuting what is called orificial stricture. The two first-mentioned sites 
are the most common. In seventy-seven out of ninety-eight examples 
of stricture, referred to by Mr. H. Smith, the constriction was found in 
the bulb, or in some part between it and the orifice ; and in twenty-one, 
in the membranous division of the urethra. 

Symptoms. — The urine is observed to pass in a gradually diminishing 
stream, which at length becomes twisted or forked. A few drops are 
left in the urethra, after all the urine seems to have been expelled. There 
is, especially after exposure to cold and damp, a sense of scalding and 
irritation along some part of the urethra during micturition, the calls to 



590 PERMANENT STRICTURE. 

which are very frequent. The bladder becomes very irritable, and the 
urine on cooling deposits a flaky mucus. Matter resembling that of 
gleet is discharged from the urethra, mingled sometimes with blood or 
pus, indicating the presence of an ulcer or abscess. If the stricture be 
of long standing, the induration of the part constricted may be felt ex- 
ternally. Besides these local symptoms, there are often tenesmus, 
hemorrhoids, pains in the loins, chronic enlargement of the testicle, 
herpetic eruption on the glans and prepuce, shooting pains in the peri- 
neum, and in severe cases, complete retention with extravasation of urine, 
or abscess and fistula in perineo. The great and constant irritation 
preys upon the constitution, and low hectic fever comes On, the counte- 
nance assuming a pallid copperish hue. 

State of the Parts. — Permanent stricture may be the result of a low 
degree of chronic inflammation, in consequence of which lymph is effused 
to a greater or less extent beneath the mucous membrane of the urethra, 
the calibre of which is thus diminished ; and this lymph, after the lapse 
of some time, becomes indurated. Or, it may depend upon the forma- 
tion either of a membranous septum stretching across the urethra and 
pierced by a small aperture, or of a simple band stretching from side to 
side. In this last case it is termed a bridle stricture. 

In a case of old stricture, the mucous membrane behind the contracted 
part may become inflamed and ulcerated ; and this condition may extend 
to the cellular tissue, and an abscess^ be formed, bursting in the peri- 
neum and constituting fistula in perineo ; or, in consequence of the 
great dilatation of the urethra behind the stricture, that canal itself 
may burst, and the urine become extravasated into the perineum. The 
prostate may become enlarged, and the bladder hypertrophied ; chronic 
cystitis, or even hernia vesicae, or first functional derangement, and 
afterwards organic disease of the kidneys may ensue. 

Treatment. — Of the various methods of treatment the most suitable 
are the three following — the use of the metallic bougie — that of the 
silver catheter — and free division of the stricture by the knife, as pro- 
posed by Professor Syme. In certain classes of cases, each of the 
methods has its special advantages. In the great majority, assuredly, 
the most suitable by far is the judicious use of metallic bougies. 

A bougie is selected of such size as is likely to pass without much 
difficulty. Having been dipped in warm water and oiled, it is to be 
passed down, and, on arriving at the stricture, to be steadily but very 
gently pressed onward, with the view of penetrating the stricture. This 
having been accomplished, it should be allowed to remain for a few 
minutes, unless the patient complain of pain, in which case it must be 
at once withdrawn. In the use of the instrument, lightness of grasp 
and gentleness of pressure* are requisite ; for to press forcibly or to 
grasp tightly would occasion the risk of either pressing the stricture 
before the instrument, or of perforating part of the urethra. If unsuc- 
cessful with the bougie first employed, others should be passed down to 
the stricture in a series of gradually decreasing sizes, until one is 
inserted into the bladder. 

When the stricture has been penetrated, the instrument remains fixed 
after the hand is withdrawn. If, therefore, the instrument resiles, it is 



PERMANENT STRICTURE. 591 

an evidence that penetration has not been effected. The first introduc- 
tion of the bougie is in some instances attended with severe pain, faint- 
ness, and rigors ; but these unpleasant symptoms are usually felt less 
at every succeeding operation. There is usually, also, after the first 
operation, ardor urinae in some degree, together with considerable pain 
for some time at the stretched parts, and increased difficulty of passing 
water. The uneasiness and irritation caused by the operation generally 
subside in the course of two or three clays. The operation should then 
be repeated, the surgeon first using the same bougie as before, then 
withdrawing it and introducing the next in size ; and this proceeding 
should be resumed at intervals until the normal size of the urethra be 
attained, and the largest bougie can be introduced without any diffi- 
culty ; after which a large one should be occasionally used at increas- 
ingly long intervals, until it be ascertained that there is no tendency to 
a return of the constriction. The cure is thus accomplished on the 
principle of dilatation, the effect of which in the first instance is mecha- 
nical, but ultimately it causes removal of the stricture by interstitial 
absorption. This mode of treatment is applicable to the great majority 
of strictures, and wherever applicable it ought to be preferred to every 
other method. 

If, however, a stricture be very difficult to dilate — or if there be an 
irregular condition of the urethra from long continuance of the disease, — 
or a false passage, or great difficulty in effecting penetration, — or severe 
rigor following each introduction of the instrument, — or a threatening 
of retention of urine, — it will be preferable to introduce a silver catheter 
through the stricture, and retain it by tapes. The orifice of the catheter 
is generally kept closed, but it is opened from time to time for the eva- 
cuation of the urine. The pressure of the catheter gives rise to a certain 
degree of irritation and swelling, in consequence of which it becomes by 
and by very firmly constricted. The irritation produces a slight grade 
of inflammation, and a considerable discharge of matter usually ensues, 
followed by widening, relaxation, and absorption, by which means the 
desired result is in most instances very speedily obtained. The instru- 
ment having become perfectly loose is withdrawn, and, after a few days, 
a larger one may, if necessary, be introduced for a short time. In the 
class of cases mentioned above, this mode of treatment is found highly 
satisfactory ; and, from what has been stated, the principle of its use- 
fulness may be easily understood. 

It must be admitted, however, that it is attended with much greater 
risk than the usual mode of treatment by the bougie, and should there- 
fore be restricted to cases in which the latter is less suitable. It is 
seldom necessary to allow the instrument to remain above three days ; 
and in some cases its use must be limited to a much shorter period. 

Some surgeons prefer the flexible catheter, but as far as my own ex- 
perience has enabled me to judge, the silver one is in most instances less 
irritating. Sir Benjamin Brodie recommends the use of a gum cathe- 
ter, mounted on a strong unyielding iron stilet, with a flat iron handle 
like that of a sound or staff. He says : " Being so mounted it is more 
readily directed into the bladder than when mounted in the usual way 
on a thin flexible wire. "When the gum catheter has entered the blad- 



o£)2 PERMANENT STRICTURE. 

der, withdraw the stilet, and Jeave the catheter with a wooden peg in 
its orifice, which the patient is to take out whenever he has occasion to 
void his urine, it being at the same time secured by a suitable bandage. 
After three or four days you may withdraw the catheter for twelve 
hours ; or if much suppuration is induced in the urethra, you may with- 
draw it for a longer period ; then introduce a larger catheter than the 
first, and thus you may, in the course of ten days or a fortnight, dilate 
a very contracted urethra to its full diameter." 

In both these methods of proceeding, namely, by the bougie and by 
the catheter, the principle of treatment is to induce absorption, the ex- 
isting cause of which is mechanical dilatation. 

Professor Syme has recommended a new proceeding for the treatment 
of permanent stricture, namely, free division of the stricture by the 
knife. The patient is put under the influence of chloroform ; and the 
limbs having been separated from each other, a small grooved director 
is passed through the stricture ; and the surgeon makes a free incision 
about an inch and a half long in the mesial line, and divides the textures 
external to the urethra over the situation of the stricture. A small 
straight bistoury is then sent into the groove of the director behind the 
stricture, and by bringing it forward the whole of the contracted part is 
divided. A No. 7 silver catheter is introduced through the urethra, and 
retained for twenty-four hours. Professor Syme has published the results 
of his proceedings, which have been very satisfactory ; and he states that 
the advantages of this mode of treatment are, that it is speedy, safe, and 
effectual. He considers it the best that could be applied, where the 
stricture is very obstinate and contractile. For the adoption of this 
method of treatment it is essential that the stricture be not impassable ; 
but Professor Syme contends that, according to his experience, no stric- 
tures are impassable. 

On this subject Professor Syme remarks : — " So long back as 1844, 
I expressed my persuasion that no stricture was truly impermeable, the 
exit of water being a certain sign that instruments might, through suffi- 
cient care be introduced. This principle of practice was obviously of 
great importance, since conviction of its truth would obviously lead to 
much more prolonged and careful exploration of the passage than would 
be thought requisite, if belief in the impermeability of stricture was 
entertained. For my own part it was frankly confessed, that, while 
sharing in the doctrine of impervious urethras, I had occasionally found 
them so, and performed the old operation, while ever since adopting the 
principle that every stricture might be permeated by instruments through 
time and care, I had not, either in public or private practice, met with 
one that proved incorrigibly obstinate." 

This treatment is only suggested as a remedy for strictures which are 
otherwise incurable. It is perfectly certain that, in many cases, this 
mode of treatment has been exceedingly satisfactory : while in a very 
few the cure has not been permanent — a circumstance which may have 
been owing to neglect of the judicious precaution of occasionally intro- 
ducing the bougie. 

Should a case, however, occur, in which an entrance cannot be effected 
either by the bougie or by the catheter, the preferable mode is to cut 



CATHETERISM. 593 

down upon the stricture and divide it. This, however, is a proceeding 
which no surgeon is justified in adopting, except under very urgent cir- 
cumstances, namely, where there is a stricture which cannot be pene- 
trated, together with retention of urine. 

The operation consists in introducing a catheter to the stricture, 
making a direct incision in the raphe down to the dilated urethra behind 
the stricture, opening the urethra and dividing the stricture by cutting 
it from behind forwards upon the catheter, which should then be sent 
back into the bladder and retained. Proper means should then be 
taken to promote the healing of the wound. 

Other methods of treatment, in which the cure is attempted on entirely 
different principles, are — subcutaneous division of the stricture ; forcing 
a passage through the stricture, as recommended by many French sur- 
geons : perforation of the stricture by a cutting instrument, commonly 
called the treatment by the lanceletted stilette, a method strongly 
advocated by Mr. Stafford for certain cases ; and the treatment by the 
caustic bougie. In this last method, the caustic potass and nitrate of 
silver have each been used. The caustic has been applied by inserting 
it into the hollow end of a common, wax bougie, but the best mode of its 
application is by the porte-caustique recommended by M. Lallemand. 
All these methods are liable to many and serious objections, and, in 
consequence, they need not here be described. 

CATHETERISM. 

No surgical proceeding can be more easily accomplished than passing 
a catheter in ordinary circumstances ; and on the other hand, as has 
been acknowledged by the most eminent practical surgeons, there is not 
in the whole range of surgical proceedings a more difficult operation or 
one that requires greater skill, caution, and experience, than that of 
passing the catheter through what has been called an impermeable 
stricture. 

1. Ordinary Proceeding. — When there is no difficulty, the catheter 
may be passed into the bladder in the following manner. The patient 
having been placed in the recumbent posture, a silver catheter having 
been selected, dipped in warm water and oiled, the surgeon takes hold 
of the penis with his left hand, and raises it up, introduces the point of 
the instrument in the meatus, with the handle directed to the belly, and 
gently slides the catheter onwards, keeping the point along the upper 
aspect of the urethra. The instrument glides onwards until its point 
engages itself in the part of the urethra embraced by the deep fascia, 
when the handle should be gently depressed, the point being still kept 
along the roof of the canal, until it glides into the bladder. In no 
part of this movement should the slightest force be used ; and it is 
unnecessary even to hold the penis in the left hand, except during the 
introduction of the instrument into the meatus and anterior portion of 
the canal. 

2. Another Proceeding. — The " tour de maitre." The instrument 
having been prepared for use, its point is introduced into the meatus 
and sent along the upper surface of the urethra, with its convexity 
directed upwards, until its point is beneath the symphysis, when the 

38 



594 RETENTION O.E URINE. 

catheter is made to perform a half turn from right to left, which brings 
the handle and concavity upwards. This manoeuvre having been exe- 
cuted, the handle is depressed and by the gentlest effort the point is 
slipped into the bladder. The only advantage of this mode is, that if 
the patient be sitting or standing, the front of the abdomen does not 
prevent a desirable position of the handle of the instrument in the first 
part of the proceeding. 

RETENTION OF URINE. 

The principal conditions which give rise to retention of urine, together 
with the appropriate treatment, now come to be considered. 

I. RETENTION FROM STRICTURE OF URETHRA. 

Should a case of retention present itself, caused by a hard and gristly 
stricture situated in front of the scrotum, and should it be found im- 
possible to penetrate the stricture by the usual gentle manipulation, in 
which the instrument is held lightly and pressed against the stricture 
without any force, the surgeon should take hold of the hard part between 
the forefinger and thumb of the left hand, and pass down the catheter 
to the stricture, and gently and cautiously effect penetration, and lodge 
it in the bladder. Should the stricture which causes retention be 
situated behind the scrotum, and should it be found impracticable to 
pass the catheter by the most cautious, gentle, and dexterous manipula- 
tion, the proper practice is to perform the old operation of sending back 
a catheter to the stricture, cutting into the dilated portion of the 
urethra behind the stricture, when the urine will escape, and dividing 
the stricture by cutting forward upon the point of the catheter, and 
sending it back so as to lodge it in the bladder. Such are the most 
advisable proceedings when retention is caused by stricture anterior to 
the prostate gland. 

II. RETENTION FROM ABSCESS IN THE PERINEUM. 

Occlusion of the urethra with consequent retention of urine is occa- 
sionally produced by abscess in the perineum. The proper practice in 
such circumstances is free direct incision, so as to evacuate the matter 
and remove the cause of obstruction. 

III. RETENTION FROM ENLARGEMENT OF PROSTATE GLAND. 

Enlargement of the prostate gland is not unfrequently a cause of 
retention. A portion of the gland rising up at the commencement of 
the urethra acts as an obstacle to the passage of the urine. This cause 
of retention can in general be readily overcome by attending to the 
following precautions : — Using a very long catheter, with a large curve, 
and the point more than usually bent — and depressing the handle to a 
much greater degree than in performing catheterism in ordinary circum- 
stances. 

The accompanying wood-cut will show the importance of these direc- 
tions. The unusual length of the catheter is necessary on account of 
the rising up of the bladder, and consequent elongation of the urethra. 
The peculiarity of form and the depressing of the handle admit of the 



SYPHILIS. 595 

instrument being sent up in front of the obstruction, instead of pressing 
against the obstruction, as would be the case in using an ordinary 
catheter in the usual way. Should all efforts to introduce the instru- 

Fig. 219. 



ment prove unavailing, the least hazardous proceeding is to perforate 
the obstruction, in doing which the greatest care must be taken that the 
point of the instrument be lodged in the prostatic portion of the urethra, 
and that it be sent in the proper direction into the bladder. Puncturing 
the bladder from the rectum, which can be safely done for the relief of 
retention when the prostate gland is not diseased, is unsafe in the con- 
ditions now under consideration. With regard to puncturing above the 
pubes, the risk of infiltration is so great that it ought not to be attempted. 
When it is necessary to penetrate the obstruction in case of a diseased 
prostate, the catheter ought to be allowed to remain in the bladder for 
some time ; and in all cases of retention, a repetition of the operation 
is very soon requisite, as secretion of urine takes place rapidly, after 
the pressure on the kidneys, caused by the distension of the ureters, has 
been removed. 

IV. RETENTION FROM PARALYSIS. 

The detrusor urinse may become paralytic in consequence of over- 
distension, injury or disease of the spine, or the feebleness of age. In 
addition to the treatment suitable to the state which has caused the para- 
lysis, the urine must be drawn off twice in the four-and-twenty hours, to 
prevent discomfort and allow the weakened parts a chance of regaining 
tone. 

SYPHILIS. 

This term is used to denote various morbid appearances, which are 
arranged into two grand divisions, namely, the local or primary, and the 
constitutional symptoms of the disease ; — the former consisting of certain 
ulcerations, commonly termed chancres, and consequent upon them, of 
swellings of glands, technically called buboes ; the latter, which are sub- 
Fig. 219. From Liston. 



596 SYPHILIS. 

divided into the secondary and tertiary symptoms, consisting of various 
morbid affections of the skin, mucous membrane, periosteum, bone, and 
other textures. 

LOCAL OR PRIMARY SYMPTOMS. 

It must not be supposed that all sores on the penis are venereal ; for 
that organ is, like other parts of the body, liable to irritation and in- 
flammation ; and common excoriation and ulcers may form on it as else- 
where. Neither must we conclude that all sores consequent on sexual 
intercourse are syphilitic, as excoriations may be produced by sexual 
intercourse, which originate in irritation, or in the contact of acrid se- 
cretions, not venereal or connected with the inoculation of syphilitic 
virus. Simple excoriations and common sores are distinguished by their 
history and appearance, and by the absence of the peculiar characters 
of the various forms of venereal ulcers. 

Venereal ulcers do not form immediately on the application of venereal 
poison ; a certain interval elapses, varying in duration according to the 
manner in which the virus is applied. When the surface to which it is 
applied is entire, ulcer rarely appears for five or six days, and often the 
interval is longer ; but when it is applied to a broken surface, the ap- 
pearances come on much more rapidly, the wound becomes painful, and 
in many instances decided symptoms of syphilitic ulcer are perceptible 
in twenty-four hours. 

There are several kinds of venereal ulcers, which, though they all 
originate from a common cause, namely, the application of venereal 
virus, yet differ materially from each other both in the character of the 
primary sores, and in the subsequent constitutional symptoms. As the 
technical term, chancre, is, strictly speaking, applicable only to those 
ulcers which have a corroded appearance, many prefer the expressions 
primary sores, or primary ulcers. Primary venereal sores are of various 
kinds ; but those which are most remarkable, and so clearly defined by 
their distinctive characters as to present no difficulty of discrimination, 
are the four following. 

I. THE SIMPLE VENEREAL ULCER. 

This, — called by some writers the common venereal ulcer, and by others 
the elevated ulcer, — is found more frequently on the internal surface of 
the prepuce, and in the sulcus behind the corona glandis, than in any 
other situations. It is often also met with on the glans, and usually 
there are more sores than one. When the sore results from the appli- 
cation of the virus to an entire surface, the first symptoms are itching 
and redness, followed by vesication, and the pustule gives way and dis- 
charges its contents either by the bursting of the cuticle, or by a portion 
of the scab becoming detached, and thus exposing the ulcer underneath. 
Such are the changes in the first or inflammatory stage. 

The form of the ulcer is usually circular, or nearly so ; its surface 
concave ; its colour pale, surrounded by a bright inflammatory areola ; 
the discharge rather ichorish ; and the pain considerable. Such are the 
appearances during the second stage when the virus contained in the 
matter is most calculated to propagate the disease. In the next stage 



SYPHILIS. 597 

the surface of the sore, instead of being depressed, becomes covered 
over with granulations, which are pale and flabby, and rise like a small 
fungus above the surrounding parts ; the ring of inflammation also 
becomes indistinct. This is the third stage, or that of reparation or 
granulation, and is succeeded by cicatrization. By these distinctive 
characters, and by the absence of any surrounding induration, phage- 
dena, or elevation of the edges, the diagnosis is easily made out. When 
the sore originates from the application of the virus to an abraded sur- 
face, the part very soon becomes painful, a scab forms, and in the sub- 
sequent progress the appearances are as already described. 

Treatment. — It is extremely desirable to arrest the progress of the 
disease as speedily as possible, since there is every reason to believe, 
that if the removal of the local disease be accomplished very early by 
the entire destruction of the part affected, a perfect protection is in the 
great majority of instances insured against constitutional symptoms. 
That the chance of securing this protection diminishes as the destruction 
is deferred, there can be no doubt ; but if it be effected within the first 
two or three days from the commencement of the specific or inflamma- 
tory process, or perhaps at any time until near the period of the burst- 
ing of the^natrix vesicle, while the disease is local, the constitution may 
be preserved untainted. It is now well known that the virus is contained 
in the discharge secreted during the second stage, and that this is con- 
sequently the period which is most favourable for the employment of the 
test of inoculation, and in which the constitution is so apt to be affected, 
or the disease to be communicated by sexual intercourse. 

A principal object, therefore, of the surgeon will be to prevent the 
occurrence of that stage ; or, to cut it short, if it be too late to prevent : 
in either case his plan will be to convert the sore into a simple ulcer by 
the entire destruction of the affected part ; or, in other words, to insti- 
tute the ectrotic treatment. Of the various means adopted for this end, 
that most generally employed is the application of the solid nitrate of 
silver, which should be applied so efficiently as to insure the complete 
destruction of the affected part. This is done in the first stage, not only 
with the view of stopping the disease, but also of affording a protection 
against constitutional sequels ; in the second stage, only with the hope 
of cutting short the disease. This is the mode of destruction which I 
have generally preferred ; and for after-dressings I have in many cases 
applied nothing but a piece of dry lint or charpie, and on the falling off 
of the scab have found the sore healed ; in other instances I have used 
water-dressings. Professor Graves objects to the application of the 
solid nitrate of silver, if the sore be large, on the ground of its being apt 
to produce bubo, and recommends the following proceeding, which I 
have adopted in many cases with the happiest results: — " Provide your- 
self with a common-sized nicely pointed camel's hair pencil, and a solu- 
tion of lunar caustic, twenty grains to the ounce ; pour a drop or two of 
this on the cover of a book or on the table, and dipping the brush in a 
basin of water, cleanse the surface of the sore with it. Dry the sore 
then completely with a piece of lint, and rinsing the brush, squeeze out 
the chief part of the water, and, pointing the brush, you may then dip 
the extreme point of it in the drop of caustic solution, so as to take up 



598 SYPHILIS. 

the smallest possible quantity of fluid, which you may then apply to the 
centre of the sore. When it has done acting, we may readily judge by the 
appearance of the surface whether enough has been applied, for the 
whole surface must be whitened ; but it is not, as is usually imagined, 
proper to burn out the edges. It may be necessary to dip the end of 
the brush in the solution, and apply it to the sore a second or even a 
third time, pausing to observe the effects of such applications. By pro- 
ceeding thus we destroy the diseased surface, and do not produce any 
inflammation likely to give rise to bubo." 

Such is the treatment in the second stage ; in the third, the immediate 
object aimed at is to repress the elevation of the granulations ; and that 
can be very conveniently done by occasionally pencilling them very 
lightly with nitrate of silver, or sulphate of copper, and in the intervals 
applying to the part either simple water-dressings, or the solution of 
the sulphate of zinc, as the appearances may indicate. 

II. ULCER WITH ELEVATED EDGES. 

The situations in which this sore is most frequently found are on the 
prepuce, both on its internal and external surfaces, in the fossa behind 
the corona glandis, and on the corona glandis itself. It is also very 
frequently found at the margin of the prepuce, where it is apt to occa- 
sion phymosis. Its formation may take place very speedily after sexual 
intercourse, if the virus has been applied to an abraded surface, or not 
till after some days, if the surface has been entire. 

The distinguishing peculiarities of this ulcer are, that the margin is 
elevated above the sore and the surrounding surface, and also slightly 
indurated ; the surface is excavated and of a brownish raw colour, and 
of irritable appearance without commencing granulations. The dis- 
charge is thin, the pain is considerable, and in some instances the 
destruction by ulceration is somewhat rapid. Among the negative 
marks of distinction are the absence of phagedena, and of induration 
of the base, or the surrounding parts. It is usual to find more than one 
sore at the same time. The treatment is the same as for the simple 
venereal sore. 

III. THE HUNTERIAN OR TRUE CHANCRE. 

The ordinary sites of this ulcer are the glans penis, the frsenum, the 
fossa behind the corona glandis, and the body of the penis. The first 
is the most frequent. The formation of this sore has been known to 
take place in one day, and, in some instances, to be delayed for weeks ; 
but it is usually found about the third or fourth day, or from that to 
the seventh, after sexual intercourse. Its distinguishing peculiarities 
are, that after a pustule containing matter, an ulcer results, the form of 
which is circular, or approaching to circular ; the edges either regular 
or very slightly indented ; the surface much excavated without the 
appearance of granulations, and covered with a viscid ash-coloured sub- 
stance ; and the base hard, with this peculiarity, that the hardness is 
usually defined and terminates abruptly, instead of gradually blending 
with the surrounding parts. The progress of the ulcer is slow, indo- 
lence of action being a distinguishing peculiarity. By these peculiari- 



SYPHILIS. 599 

ties, together with the negative signs, namely, the absence of phage- 
dena, and of a surrounding areola of inflammation, the diagnosis is 
easily made out. This ulcer, unlike the former, is in most instances 
solitary. 

The treatment of this chancre is the same with that of the two former, 
except that a much more extensive destruction, by means of nitrate of 
silver, is necessary in order to insure the entire removal of all the parts 
affected with hardening, and the formation of a simple healthy ulcer on 
the separation of the eschar. Some surgeons have employed potassa 
fusa to effect destruction of the diseased parts ; I have no experience of 
its use in these cases, having always preferred nitrate of silver, both 
because its application is attended with much less pain, and also because 
the extent of destruction is more easily regulated. Lint dipped in 
water, in the solution of the sulphate of zinc, or in the black wash, may 
be applied in the ordinary dressings, as the appearance of the ulcer 
may indicate. To the employment of mercury in the treatment of the 
primary sores, we shall refer in a future page. 

IV. PHAGEDENIC SORE. 

The three varieties, namely, phagedena, or phagedenic sore, slough- 
ing or gangrenous, and sloughing phagedena, called by some writers 
the phagedena gangrenosa, are so similar to each other in the circum- 
stances in which they are found, in their symptoms and in their treat- 
ment, that it will be more convenient to describe them together than to 
assign a separate section to each. The term phagedena, derived from 
<pccyu, to eat, is well applied to this kind of ulcer, as there is the appear- 
ance of regular eating away, or destruction by phagedenic ulceration, 
without any attempt at granulation. This kind of destruction, though 
most commonly seen as a form of syphilis, is by no means confined to 
syphilitic disease. 

Phagedena, or a phagedenic ulcer, may be distinguished by the fol- 
lowing peculiarities. The edges are extremely irregular and of a dark 
purplish appearance, a red colour extending a considerable way into the 
surrounding parts ; they are exceedingly painful, and at parts inverted ; 
the surface of the sore is uneven, and extends underneath the edges ; 
it is of a livid or dark red colour, and together with the edges has a very 
irritable appearance. It is covered by a thin ichorish bloody discharge. 
The sore enlarges with alarming rapidity, and the destructive process 
may continue to be carried on either by ulceration alone, or, which is 
more common, by ulceration together with sloughing, so as to consti- 
tute the variety called by some writers, the sloughing phagedena, and 
by others the phagedena gangrenosa. In the other variety, namely, the 
sloughing sore, the destruction is by sloughing alone ; the sore enlarges 
by the formation of one^slough after another, and the surface of the sore 
on the separation of the slough, instead of presenting the appearance of 
granulations, has a raw, red, irritable appearance. These three varie- 
ties exhibit the same appearance of edges, and occur in similar circum- 
stances ; they differ chiefly in the appearance of the surface of the sore, 
there being in the phagedenic sore an irregular appearance of the sur- 
face, occasioned by the ulcerative process ; in the sloughing phagedena 



600 SYPHILIS. 

the same appearance at some parts, and a wet ash-coloured slough at 
others ; and in the sloughing variety a wet slough covering the sore. 
The characters of these ulcers are so peculiar that there can be no diffi- 
culty in distinguishing them from each other, or from any of the syphi- 
litic ulcers formerly described. A high degree of constitutional dis- 
turbance attends each of these three varieties. The tongue is white, 
the skin dry, the pulse quick and small, with loss of appetite, prostra- 
tion of strength, and the other symptoms of high irritative fever ; which, 
when the disease is extensive and of long continuance, is apt, and some- 
times quickly, to assume the typhoid type. Individuals whose consti- 
tutions have been rendered irritable by intemperance, by want of proper 
food or regular rest, by living in damp or confined situations, or by 
leading irregular lives, are those in whom phagedenic ulceration is most 
apt to take place, and in whom it is likely to proceed to the most alarm- 
ing results. On this subject Professor Samuel Cooper says, — " The 
causes of phagedenic ulceration may frequently be traced to the condi- 
tion of the individual's health ; to his having neglected to restrict him- 
self to proper regimen ; to his having been guilty of excess ; or to his 
having neglected some other kind of primary sore at its commence- 
ment." 

The treatment of these three varieties is both constitutional and local. 
The object of the former is to improve the general health, to increase 
the strength, and to allay the irritability of the system. The means to 
be employed must be regulated by the particular circumstances of each 
case. The skin should be kept in a soft state, the general irritability 
of the system and the pain of the sore allayed, and if the patient have 
restless nights, means must be taken to procure sleep. For the fulfil- 
ment of these indications many combinations of remedies may be service- 
able ; but that which is used by many practitioners, and which I have 
often employed with the happiest effects, is the liquor ammoniae acetatis, 
combined with morphia, and given at bedtime, in doses proportioned to 
the age of the patient and the urgency of the symptoms. A most impor- 
tant indication is to promote a healthy condition of the digestive appa- 
ratus ; the bowels should be carefully regulated, and the diet be most 
nourishing in quality and easy of digestion. The patient should be kept 
in an airy situation, the part kept at perfect rest, and everything guarded 
against which might exert any depressing influence or any untoward 
agency on the general system. 

Such, in the great majority of cases, are the most important objects 
aimed at by constitutional treatment, but the use of other remedies may 
be indicated, and the surgeon in every case must act as the symptoms 
may suggest. As to local treatment, various modes have been adopted. 
An application, strongly recommended by Sir Astley Cooper, and often 
used, especially when the destructive action is not extremely rapid, is 
the nitric acid lotion, of the strength of from thirty to fifty drops to a 
quart of water. I have in many instances in my own practice, and in 
that of my friend and predecessor in this university, Dr. Ewing, seen 
this application used with the happiest effects in conjunction with the 
constitutional treatment above described. As soon as the character of 
the sore becomes healthy, simple dressings should be applied. Two 



SYPHILIS. 601 

opposite methods, the one mild and soothing, the other of the most ener- 
getic character, have been recommended by different surgeons for the 
treatment of this ulcer. The former method, the object of which is, by 
soothing the irritability of the part, to diminish the inflammation and 
induce a more mild and healthy action, consists in the application of 
emollient and opiate poultices, or of emollient poultices, and opiate oint- 
ments to the affected part ; the linseed poultice prepared with a decoc- 
tion of opium is the application often preferred. Of the various appli- 
cations employed in the energetic practice, the object of which is to 
destroy the whole of the diseased part, the pure nitric acid is the most 
frequently recommended. The sore should first be well dried, and the 
acid then applied by means of lint soaked in it, and in such a manner 
as to destroy not only the diseased surface, but also the margin and 
subjacent parts, in which violent inflammatory action is going on. The 
surface is very speedily converted into an eschar. If any of the acid 
should spread from the sore, it should be carefully wiped away, that 
the surrounding parts may not be injured ; a powerful opiate should be 
administered to diminish the pain, and the application of poultices kept 
up to promote the separation of the eschar ; after which the treatment 
should be changed for that which is proper in a simple healthy ulcer. 
As far as my own experience goes, I am decidedly in favour of the 
latter method of treatment, and invariably have recourse to it on finding 
that the soothing system has not had the desired result. In cases where 
the morbid action is not so violent, the application of the weak nitric 
acid lotion, together with mild poultices and suitable constitutional 
treatment, is often followed by the most beneficial results. 

The above statements, it is hoped, will be sufficient to point out clearly 
the distinctive characters, and the treatment of the principal forms of 
primary venereal sores. 



The Consecutive or Constitutional Symptoms of Syphilis are divided 
into two grand classes, the secondary and tertiary ; the former compre- 
hending certain eruptions on the skin, affections of the mucous mem- 
brane, and iritis ; the latter, affections of bone, periosteum, certain 
tubercular affections, assuming in many cases the characters of rupia 
prominens, and ending in irritable sores, affections of the mucous mem- 



brane, and iritis. 



SECONDARY AFFECTIONS. 



The principal eruptions are the papular, the pustular, the scaly, and 
the tubercular. 



I. THE PAPULAR ERUPTION. 



The papular eruption, or venereal lichen, as it has been designated, 
is preceded by fever, which is attended with pains in the head, shoulders, 
knees, and larger joints, and sometimes in the chest, where a feeling of 
anxiety is at times experienced. The pains are most severe at night, 
and the febrile symptoms, which are at their height before the appear- 
ance of the eruption, do not cease when the eruption comes out, but 



602 SYPHILIS. 

continue as long as successive crops appear. The eruption is of the 
papular form, the part being at first of a red colour, varying in bright- 
ness in different cases ; by and by, however, there is the appearance of 
pustules with elevated tops, containing lymph or matter ; and after- 
wards, when the eruption is on the decline, it presents in the desquamat- 
ing stage a scaly appearance from exfoliation of the cuticle ; the colour 
being in this stage much paler, and having a copper tinge. The time 
of the appearance of the eruption after the primary symptoms is very 
variable. In many examples the eruption is found all over the body, 
but it is usually most copious on the face, chest, back, and belly ; and 
frequently, after having entirely subsided, it returns at very uncertain 
intervals, but each successive attack is in general less extensive, and 
accompanied with less febrile derangement. Passive inflammation of 
the conjunctiva is very frequently an accompaniment of this eruption ; 
and it is almost invariably attended with inflammation of the mucous 
membrane of the throat, the back of the pharynx, the tonsils, and the 
fauces for the most part being red and swollen, and presenting a raw 
appearance, and often covered with an aphthous coating. There is 
difficulty of deglutition, and at times the glands of the neck become 
swollen. It is of the greatest practical importance not to confound the 
desquamating stage of the papular eruption with the scaly eruption to 
be presently described. 

The exhibition of mercury forms no part of the proper treatment of 
this affection, experience showing that when taken before the appear- 
ance of the eruption it increases the fever and local pains, and when 
after its appearance, it seems to be followed by increase of the local 
pains, and recurrence of eruption. It is only after the desquamating 
stage is over, that its exhibition can be ventured upon w r ith any advan- 
tage, and, indeed, without being injurious ; and even then it is not es- 
sential, or even useful, except when given in small alterative doses, 
and combined with some antimonial, or with sarsaparilla. The treat- 
ment which is recommended by many authorities, and which I have 
found very satisfactory, consists in the strict employment of the an- 
tiphlogistic regimen, until all febrile symptoms have completely sub- 
sided ; in purging the bowels very smartly at the commencement, and 
afterwards keeping them in an open state by cooling aperient medi- 
cines ; in producing determination to the skin by saline, antimonial, and 
other suitable diaphoretic medicines, so as to promote the coming out of 
the eruption ; in preserving the surface of the body warm; in enjoining 
confinement to the house while painful symptoms continue ; in the oc- 
casional use of the warm-bath, the use of nutritious, but light and di- 
gestible food, and after the subsidence of the eruption and of all febrile 
symptoms, the employment of a course of sarsaparilla and iodide of 
potassium, with all judicious means for restoring the strength and im- 
proving the general health. 

II. THE PUSTULAR ERUPTION. 

In this, as in the former case, the appearance of the eruption is pre- 
ceded by febrile symptoms, with local pains. In some persons succes- 
sive crops, and also the coexistence of pustules in different stages, are 



SYPHILIS. 603 

observable. The matter which forms, dries into a thick scab, below 
which a superficial ulcer is concealed, the mildness of which, and the 
absence of any tendency to spread, distinguish it from the tubercular 
eruption. On the healing up of the ulcer and the separation of the 
scab, the cicatrix has a discoloured appearance. The same treatment 
is found useful as in the papular eruption. 

III. THE SCALY ERUPTION. 

The scaly eruption, as was noticed by Hunter, is sometimes preceded 
by efflorescence of the whole body, and presents, as Dr. Willan remarked, 
a mottled-red appearance of the skin, similar to that of roseola anulata ; 
this, however, in a short time passes away, and leaves the skin covered 
with scurfs or scales. The scaly eruption usually exhibits the appear- 
ance either of syphilitic lepra, or of syphilitic psoriasis. 

In syphilitic lepra the spots on the skin are of a circular form, of a 
reddish, or what is called a coppery colour ; they are a little elevated 
above the surrounding surface, and the circumference of each spot is 
rather more elevated than its centre. The patches in general are dis- 
tinct and at a distance from each other ; they are of a bright colour, 
and the cuticle over them desquamates, giving to the spot a scaly ap- 
pearance. The eruption is usually most copious upon the forehead, back 
of the neck, trunk, and groin. 

In syphilitic psoriasis the spots, instead of being circular and large, 
are small, irregular, and less elevated. The appearance caused by this 
eruption varies in different parts of the body ; for example — when parts 
are affected which are naturally in contact, as when it is between the 
nates or under the arms, the skin instead of presenting a scaly appear- 
ance, becomes elevated and moist, is destitute of scales, and is covered 
with a whitish secretion ; when it attacks the palms of the hands, or the 
soles of the feet, instead of forming scales, the whole cuticle is thrown 
off, and is followed by the formation of another cuticle, which is thrown 
off in the same manner. The affection of the throat which accompanies 
the scaly eruption, is peculiar; the tonsils are the parts usually affected, 
and, to use the language of Hunter, there is "a fair loss of substance, 
part being dug out, as it were, from the body of the tonsil with under- 
mined edges. This is commonly very foul, having thick white matter 
adhering to it, like a slough which cannot be washed away." 

With regard to the treatment of the scaly eruption, most surgeons of 
great experience agree that mercury is the most valuable remedy, when 
judiciously given, in moderate doses, and only to such an extent as will 
not produce derangement of the general health, or excite much, if any, 
salivation. The rule I have observed in the employment of this medi- 
cine is, to discontinue its use as soon as the eruption disappears, or the 
gums become in the slightest degree affected. The effects of mercury 
in the scaly and papular eruptions are very different indeed : and 
hence arises the importance already mentioned of not mistaking for the 
former the desquamating stage of the latter. It is always- necessary, 
however, to remember that mercury in this as well as in other states, 
must be administered with judgment and discretion. If there be much 
accompanying pain, or an irritable state of constitution, or much de- 



604 SYPHILIS. 






rangement of the general health, the employment of mercury will not 
only not be useful, but will prove positively injurious. The proper 
treatment for such states should, in the first instance, be instituted, and 
when the symptoms unfavourable to the use of mercury have been re- 
moved, it may then be tried, and its employment will be attended in 
many instances with the happiest results. 



IV. TUBERCULAR ERUPTION. 



This form of eruption is usually preceded by languor, debility, severe 
nocturnal pains, and derangement of the general health. Tubercles, 
but little raised above the surrounding surface, make their appearance ; 
they are very painful and irritable ; the skin becomes red, and after its 
ulceration a crust forms, the removal of which exposes a foul and very 
irritable ulcer, with inflamed irregular edges, and with no disposition to 
take on a healthy action. In many instances these ulcers after some 
time exhibit a peculiar appearance, in consequence of a healing process 
taking place in the centre, while the ulcer extends at its circumference 
by phagedsenic edges. The joints, and especially the knees and ankles, 
are often exceedingly painful, the pain increasing at night, and in many 
cases they are actually inflamed. The affection of the mucous mem- 
brane, which accompanies this eruption, is of a most formidable charac- 
ter. Beginning generally on the pharynx or velum palati, where an 
aphthous sore presents itself, it rapidly spreads along the mucous mem- 
brane of the throat and nose, and is extremely apt to give rise to de- 
struction of the hard and soft palate, as well as to extensive caries, and 
destruction of the spongy, ethmoid, and other bones, with the usual 
train of distressing consequences resulting from that destruction. This 
eruption is, even under the most favourable circumstances, of a formi- 
dable character ; but when it takes place in individuals of a scrofulous 
diathesis, and when the system has been rendered irritable by intempe- 
rance or by the injudicious use of mercury, its consequences are usually 
painful in the extreme. 

The treatment of this form of syphilis is often very unsatisfactory ; 
and the employment of mercury in any of the various forms in which it 
is administered, is almost invariably found to be most prejudicial in the 
exceedingly weak and irritable state of constitution which attends the 
tubercular eruption. In the febrile state which often precedes, as well 
as accompanies, this affection, the diet should be unstimulating ; the 
state of the stomach and bowels should be particularly attended to, and 
a healthy performance of their functions promoted by the exhibition of 
such remedies as in the particular circumstances of the case seem most 
calculated to correct derangement. When pain is very considerable, 
opiates are indispensable ; and in order to obtain relief, to secure rest, 
and to allay the irritability of the system, they should be used cautiously 
and sparingly ; the state of the skin, however, must be attended to ; 
and in some cases mild antimonials and the occasional employment of 
the warm bath are useful. When the febrile symptoms subside, the diet 
should be generous, but light and digestible; and all available and judi- 
cious means should be employed for improving the general health. 
When the state of the digestive system is improved and the febrile symp- 



SYPHILIS. 605 

toms have subsided, the greatest possible benefit is often found to accrue 
from the employment of a course of sarsaparilla and the iodide of potas- 
sium. The best local applications for the ulcers on the surface of the 
body are, in the first instance, poultices, with the occasional application 
of the nitrate of silver, or the nitrate of mercury, or the weak nitric acid 
lotion, and afterwards simple water dressings ; and for the affection of 
the throat the best are, the application of the nitrate of silver in sub- 
stance, or the occasional application of a liniment of the proto-ioduret of 
mercury, of the strength of twenty grains to half an ounce of honey, or 
the fluid nitrate of mercury considerably diluted. 

The Tertiary Affections, consisting of certain tubercular formations, 
having many of the characters of rupia prominens, and often degene- 
rating into foul and irritable ulcers ; affections of the periosteum ; of the 
bones, often ending in ulceration, or caries, or necrosis, or nodes, or 
enostosis, a most formidable affection of the mucous membrane of the 
throat and nostrils, giving rise to very distressing results, and iritis, 
seldom occur until a long period after the cessation of the primary symp- 
toms, and rarely until after the secondary symptoms have either disap- 
peared entirely or ceased for a very considerable time. The treatment 
of these affections must be conducted according to the general princi- 
ples formerly laid down. 

Having now detailed the primary and consecutive forms of syphilis, 
we shall conclude this subject with some remarks on the following points ; 
namely, on the effects of inoculation with matter taken from the primary, 
secondary, and tertiary forms of the disease ; and on the use of mercury 
in the treatment of syphilis. 

The results of inoculation have been carefully attended to by many 
observers, and by none more exactly than by M. Bicord of Paris. The 
results of his experiments are, that the pus of primary syphilitic sores 
in their ulcerative and progressive stages produces the characteristic 
pustule, whilst that of secondary and tertiary syphilis produces nothing, 
any more than that of chancres in the period of reparation. In other 
words, primary syphilis is communicable by inoculation, but secondary 
and tertiary are not. The results of M. Ricord's experiments are con- 
firmed by those of Dr. Mairion, who made experiments in not fewer 
than two hundred and fifty-seven patients in the Military Hospital at 
Louvain ; and not only in the results of inoculation, but also as to their 
being communicable from one person to another, the primary, secondary, 
and tertiary forms of syphilis, present remarkable differences. Primary 
syphilis is communicable by inoculation and by contagion ; the latter in the 
intercourse of the sexes, being the most common means of propagating 
the disease — the thin condition of the epidermis, the moisture and fric- 
tion all rendering absorption easy. Some cases are recorded in which 
the disease was communicated to the fingers of medical men by inocu- 
lation, while making the necessary examinations per vaginam in labours. 
Secondary syphilis, although not communicable by inoculation, is by 
inheritance ; and also, beyond all doubt, from mother to child, from 
husband to wife, and from nurse to child, the virus being communicated 
through the medium of tainted secretion. The mouth of the infant, for 
instance, infects the nurse, or the breast of the nurse the mouth of the 



606 SYPHILIS. 

infant ; and in such cases there is often considerable difficulty in de- 
termining whether the disease has passed from nurse to child, or from 
child to nurse. On this subject M. Ricord remarks, " The organs of 
the mouth are often the propagators of the contagion by a lascivious 
kiss, by the application of the lips or tongue to some part of the mucous 
membrane, by suction of the breasts, and especially in suckling. If 
the mouth of an infant can infect a nurse, the breast of a nurse can 
infect a child. These alternative affections are only too frequent ; — 
hence arises a question : Is there any means of determining whether the 
disease has passed from the nurse to the child, or from the child to the 
nurse ? If the disease exist in both individuals at the same time, and 
has arrived at the stage of consecutive disease, one can only form a 
probable opinion from the state of health of the father and mother, the 
child, and husband of the nurse, and from the time at which the disease 
showed itself in one or other of them, which it is sometimes very diffi- 
cult to ascertain. But one may be certain that the child has communi- 
cated the disease to the nurse if it has ulcers in the fossas nasales, 
tubercular pustules in a scaly or ulcerated state in any part of the body, 
with marks of a disease already of long standing. On the other hand, 
we may be certain that the nurse has infected the child, if she has ulcers 
at the anus, pustules on the body, or exostoses, and the child simply 
ulcerations of the mouth, nose, or anus." 

On the use of Mercury. — The indiscriminate use, and the indiscrimi- 
nate withholding of mercury in the treatment of syphilis, are both prac- 
tices which are now generally allowed to be extremely injudicious ; and 
which, fortunately for mankind, are in a great measure abandoned. That 
much mischief has been done by the profuse and indiscriminate exhibi- 
tion of mercury ; that primary, secondary, and tertiary symptoms have 
often been aggravated, and frightful mutilations often been induced by 
the improper and excessive use of this medicine, and that such severities 
and mutilations are much less common since a milder and more prudent 
practice has prevailed, are propositions regarding the truth of which there 
is no reasonable ground of doubt. But the opinion maintained by some 
writers who are unfavourable to the use of mercury, that to this medicine, 
and not to syphilis, are to be ascribed many affections of the skin, nose, 
throat, iris, periosteum, and bones — in short, the conditions which are 
usually regarded as the secondary and tertiary forms of syphilis, is 
clearly incorrect, inasmuch as these affections may occur, and often 
have occurred, in syphilitic patients, who have not taken any mercury ; 
whereas in no instances where mercury is given in other diseases, do we 
find it produce eruptions and other affections like those of syphilis ; in 
no instances do we find it produce iritis, disease of the nose, or of the 
bones. In short, these affections may be produced by syphilis without 
mercury, but they do not result from mercury without syphilis. 

Ever since syphilis broke out in this country, mercury has more than 
any other medicine obtained the general confidence of the profession, 
notwithstanding much random and injudicious practice in its exhibition, 
from a notion which at one time prevailed, that it is not only a specific 
for syphilis, but that the disease could not be cured without it ; and not- 
withstanding, also, the many substitutes for it which have been at various 



SYPHILIS. 607 

times proposed, such as sarsaparilla, guaiacum, nitric, nitro-rnuriatic 
acids, and other medicines. Mr. Rose, while surgeon to one of the Re- 
giments of Guards, instituted the treatment of syphilis without mercury, 
in the numerous cases which came under his care in the Regimental Hos- 
pital : and he there found that the primary sores got well without mer- 
cury, and that the secondary symptoms generally exhibited nearly the 
same characters as usual, and were, as well as the primary symptoms, 
removed without mercury in every instance, a few cases of iritis ex- 
cepted ; and from these results Mr. Rose concluded, that syphilis is 
curable without mercury. Many army surgeons adopted the same views, 
followed the same practice, and found the same results. The strong 
constitutions of the soldiers, the strict regulation of their diet, and 
freedom from exposure to cold and damp while under treatment, were 
all favourable for enabling them to throw off the poison of syphilis, and 
are supposed by some surgeons to furnish an explanation of the success- 
ful results of this treatment in the cases mentioned. Mr. Rose found 
that the same treatment was not successful in private practice, and in 
consequence he returned at length to the usual mode of treatment, and 
prescribed mercury. The opinion, therefore, which experience seems 
to justify is, that as yet we are not acquainted with any remedy of the 
same efficacy as mercury for extirpating the poison of syphilis. It is 
not, however, as has been already stated, to be used in every case, but 
with due discrimination ; and whenever it is prescribed, it ought to be 
with moderation, and on no account be employed further than slightly 
to affect the gums. 

In cases of primary sores, if the ectrotic treatment has been success- 
fully employed, there is no poison in the system to extinguish, and 
therefore mercury is not given. When the ectrotic treatment has not 
been tried, or not been successful, mercury is given in the first three forms 
of primary sore, but especially in the third. Some limit its use to the third 
and to obstinate cases of the second, not allowing it at all in the first, in 
which it certainly does not seem so essential. For my own part, I have 
only prescribed mercury for those cases of the first variety of primary 
sore which proved obstinate after the use of other remedies. In the 
phagedenic sore, the use of mercury would aggravate the symptoms, 
and it ought therefore not to be prescribed. In some cases of secondary 
and tertiary symptoms it is both advisable and necessary ; in cases of 
papular eruption, as has been already stated, it is almost always inju- 
rious, except as a mild alterative after the subsidence of the eruption. 
In the pustular eruption it may be given, if the treatment previously 
recommended has not had the desired effect, and the disease persists or 
returns ; in the scaly eruption, and especially after the Hunterian 
chancre, it is indispensable, and of the greatest advantage ; in tertiary 
affections of the skin, which have not yielded to other treatment, in pe- 
riostitic affections of tertiary occurrence, and in all cases of iritis it 
ought to be prescribed. These are the principal cases in which mercury 
is essential. The conditions in which its use is undesirable are, an in- 
flamed phagedenic, or sloughing condition of sores, whether primary or 
consecutive ; febrile excitement ; the syphilitic affections succeeding on 
the phagedenic form of primary sore ; the strongly-marked scrofulous 
diathesis ; and a weak and irritable condition of constitution. 



608 



CHAPTER XVIII. 

AMPUTATIONS AND KESECTIONS. 



In his admirable work on Practical Surgery, the lamented Mr. Lis- 
ton remarks, " The operation of amputation is not so frequently had 
recourse to now as heretofore, and the progress of surgical information 
will probably render it even more rare than at present." In the inte- 
resting Biographical Sketch of Sir Benjamin Brodie, given in the Lan- 
cet of May 4, 1850, the writer remarks, " The result of the progress 
of modern surgery has been to make the knife more daring than ever 
upon real occasions, but to keep it inactive, unless upon ample cause for 
its exercise. Never were human limbs held in greater respect and 
treated more conservatively than at present. We owe much of this state 
of things to Sir Benjamin's efforts in diagnosis and pathology." Not- 
withstanding this exceedingly gratifying result of progress in diagnosis 
and pathology, there are still many cases where it is necessary to sacri- 
fice a limb in the hope of preserving life. 

The principal conditions which present this necessity are diseases of 
joints or bones, for which the operation of resection is unsuitable, and 
when the continuance of the disease must inevitably shorten life ; cases 
in which a limb is so severely injured that the surgeon is firmly con- 
vinced its preservation is impossible ; cases of chronic gangrene, after 
the formation of a line of demarcation ; and cases of spreading gangrene 
produced by an external cause, such as a gunshot wound, or compound 
fracture, or other injury, when there is a sound part in which the ope- 
ration can be performed. However unpromising an operation may be 
in the last-mentioned circumstances, it affords the only chance of saving 
the patient's life. Such are the principal conditions which present an 
urgent necessity for resorting to amputation, and render its perform- 
ance an unavoidable duty, for, as Dionis says, "it is better for the 
patient to live with three members than to die with four." There is 
also a class of cases in which amputation, though not absolutely neces- 
sary, may be said to be justifiable, namely, when a limb has from stiff- 
ness and an awkward position become not only useless, but extremely 
inconvenient. In such circumstances, when a patient expresses a strong 
desire to have the limb removed, the surgeon is justified in yielding to 
his solicitation ; and the proceeding is then called an operation of " com- 
plaisance." 

Two of the greatest improvements we read of in the history of ampu- 
tation are, the application of the tourniquet for the temporary, and the 



AMPUTATIONS. 609 

employment of the ligature for the permanent suppression of hemor- 
rhage. The tourniquet was invented by Morel in 1674, and improved 
by Petit in 1718. Its application for arresting hemorrhage during the 
operation diminished the danger of amputation, which accordingly 
became more frequent after its adoption. Useful, however, though it 
is, and deserving to be employed when there is a scarcity of trustworthy 
assistants, a more advantageous mode of arresting hemorrhage is now 
preferred, namely, compression of the artery leading to the part by the 
fingers or thumbs of an assistant. One great advantage of this method 
over that by the tourniquet is, that while it arrests the great flow of 
blood into the limb by the main trunk, it does not prevent the return 
by the veins of that which finds its way by collateral smaller channels, 
and hence there is not that excessive congestion of the limb, or that 
gush of venous blood which follows the introduction of the knife when 
the tourniquet is employed. It is almost unnecessary to remark, that 
in many instances it is of the very greatest importance to lose as little 
blood of any kind as possible ; and of this I am firmly convinced, that 
when the charge of the main artery is committed to an intelligent and 
trustworthy assistant, as a general rule, there will be less loss of blood 
than when the tourniquet is employed. The pressure should not be 
applied until the knife is just ajpout to be introduced. 

A still more important event in the history of surgery is the employ- 
ment of ligature by Ambrose Pare, in 1582, for permanently arresting 
hemorrhage. To this truly great man, the first surgeon in Europe of 
the age in which he lived, a man of whom France may well be proud, 
belongs the merit of introducing the ligature as a surgical means of per- 
manently arresting hemorrhage ; an improvement, second to none in 
the history of surgery, for of all hemostatics it is unquestionably the 
safest and best. Pare says, " For the good of mankind and the improve- 
ment and honour of surgery, I was inspired by God with this good 
thought." It has been remarked that, " as it was the highest of all his 
improvements, it was the one for which his enemies envied him the 
most." Previous to his time some of the many means used for sup- 
pressing hemorrhage were plunging the stump into boiling oil and pitch, 
the actual cautery, the vitriol button, and the use of a red hot knife in 
the amputation ; and it surely is one of the most disgraceful facts in 
the history of surgery, that the physicians and surgeons of those days 

Fig. 220. 




and their successors for some time, instead of honouring the man, adopt- 
ing his invention, and thus promoting the improvement of their profes- 
sion and the welfare of mankind, contemned his invention and contended 
more violently than ever for the actual cautery. Fortunately for those 




610 AMPUTATIONS. 

who have to suffer amputation, the invention of Pare did at last prevail, 

and he has long been regarded not only as 
Fig- 221 - one of the great ornaments of surgery, but 

as one whose labours have proved invalu- 
able to mankind. — The best material for 
ligatures is strong, firm, silk thread. Of 
the two instruments for seizing the open 
mouth of an artery, namely, the tenacu- 
lum, and the spring artery forceps, the 
latter, represented above, is the preferable ; 
and for tying the ligature the best knot is 
that called the reef-knot, which will be bet- 
ter understood from the accompanying representation than from any 
description that can be given of it. Deligation should be effected care- 
fully and firmly, and one end of the ligature should then be cut off. 

In all amputations of importance one assistant is required to command 
the artery, another to administer chloroform, to watch its effects, and 
attend to the patient generally, — a third to take charge of the flaps, and 
to tie the arteries as they are seized by the operator, and a fourth to 
hold the limb, and after its removal to hold the stump. Another assis- 
tant may be employed to hand instruments, sponges, ligatures, water, 
&c. ; but it is better to have all these things conveniently placed, so that 
the surgeon may easily lay his hand on whatever he may require. Am- 
putation can easily be effected with fewer assistants, but in a public 
hospital, or where they can be conveniently obtained, the proceeding 
may be conducted satisfactorily and speedily with the number mentioned 
above. 

AMPUTATIONS OF THE UPPER EXTREMITY. 
AMPUTATION OF A PART OR THE WHOLE OP A FINGER. 

This may be accomplished either at one of the phalangeal articulations, 
or through one of the phalanges ; the former operation is called by 
some, amputation in the contiguity, the latter, amputation in the con- 
tinuity of the phalanges. 

Amputation at any of the phalangeal articulations may be effected 
by any of the following modes, and the most convenient instrument for 
the operation is a narrow, long, straight bistoury, such as that repre- 
sented below. 

First proceeding. — A piece of bandage or surgeon's lint having been 
applied around the part to be removed, so as to afford a more secure 
hold for the surgeon while making the necessary movements for facilita- 
ting the progress of the knife, place the hand in the prone position, take 
hold of the part to be removed, bend it slightly, apply the long, narrow, 
straight bistoury to the radial border of the joint, carry it across the 
joint, to the inner side so as to make a lunated incision of the skin, then 
run the knife rapidly from point to heel across and into the joint, extend 
the finger when the knife is through the joint, and carry the knife for- 
ward parallel to the bone, and in close contact with it, bringing it out 
so as to finish with a semilunar flap, which must be sufficiently long to 



AMPUTATIONS. 



611 



cover the extremity of the bone and to unite with the lunated extremity 
of the skin on the posterior aspect. 

Fig. 222. 




Seco7id proceeding. — Place the hand in the prone position with the 
finger straight, apply the knife to the radial border, run it across in a 
lunated direction on the posterior aspect to the inner side, and then 
without raising the knife transfix below tne joint, introducing the knife 
at the inner, and bringing it out at the outer extremity of the incision, 



Fig. 223. 




and complete this first incision by making a flap in front sufficiently 
long to cover the extremity of the bone : then apply the knife to the 
upper part, and with one stroke effect disarticulation. 



612 AMPUTATIONS. 

By this mode amputation can be performed very rapidly and ele- 
gantly, the knife being applied only twice to the finger, the first move- 
ment dividing the integument on the posterior, or, as the finger is placed 
in the operation, the superior aspect, transfixing, and making the long 
flap on the anterior, or inferior aspect ; and the second movement 
effecting disarticulation. 

Third proceeding . — Place the hand in the supine position, extend the 
finger, transfix on the palmar aspect of the joint, carry the bistoury at 
first parallel to the bone, then bring it out so as to form a flap semicir- 
cular at the extremity, and sufficiently long to cover the bone, and unite 

Fig. 224. 




with the skin on the dorsal aspect, then apply the knife to the front of 
the joint, carry it through the articulation, and divide the soft parts on 
the dorsal aspect without forming a flap, by bringing the knife to the 
surface. 

This is also a very nice mode of performing this operation. 

By any one of these methods this amputation may be effected by a 
person of ordinary dexterity in an amazingly short time ; for my own 
part, I usually give the preference to one or other of the two last men- 
tioned. 

AMPUTATION THROUGH ANY OF THE PHALANGES. 

These operations are exceedingly simple, and easily performed. The 
following is the usual mode. Place the hand in the prone position with 
the finger perfectly straight ; transfix with the long, narrow, straight 
bistoury at the part where the bone is to be divided, and make a long 
flap on the palmar aspect ; complete the division of the soft parts by a 
lunated incision across the dorsal aspect, making a short flap ; and finish 
the amputation by dividing the bone with the bone forceps. Two 
arteries may require to be tied in these operations ; the soft parts should 
be brought into the proper position, and retained by means of a single 
stitch ; a piece of lint dipped in water should be applied, and after- 
wards the part should be dressed in accordance with common principles. 

REMOVAL OF THE ENTIRE FINGER. 

Without being at the time aware that Mr. Fergusson resorted to the 
same proceeding in cases where the entire finger required to be removed, 
I many years ago preferred removing along with it the extremity of the 



AMPUTATIONS. 



613 



metacarpal bone to performing disarticulation at the metacarpophalan- 
geal articulation. The execution of either operation is as easy as could 
be desired, but the former has the advantage of producing less deformity, 



Fig. 225. 



Fig. 226. 




as the adjoining fingers can be made to approach each other when the 
extremity of the metacarpal bone is removed, and it is surprising how- 
little of an unpleasant appearance the hand presents in many instances 
after this operation. The best mode of proceeding is, to place the hand 
in the prone position, to direct an assistant to separate the fingers from 
the one to be removed, and then to make an incision along the posterior 
aspect of the metacarpal bone, beginning a little above the place where 
the bone is to be cut through, and terminating in two incisions, one 
extending along each side of the finger, and meeting each other a little 
in front of the palmar aspect of the joint. The soft parts should next 
be separated from the bone, the bone cut through with the bone forceps, 
and the finger and part of the metacarpal bone removed. After tying 
the arteries, the edges should be brought together by a stitch or two, 
and the fingers approximated. After the healing of the part, the only 
mark left will be a single straight cicatrix along the site of the operation, 
the soft parts being left perfectly entire on the palmar aspect of the 
hand. This is a very satisfactory, and, as it appears to me, the best 
mode of performing this operation. Care must be taken in the after 
treatment to keep the fingers nearly parallel, and not allow them to 
plait over each other. 

AMPUTATION OF THE THUMB. 

The phalanges of the thumb are amputated in the same way as those of 
the fingers. When both phalanges require to be removed, the metacarpal 

[Figs. 225, 26. From Fergusson. — Ed.] 



614 



AMPUTATIONS. 



Fig. 227. 




bone should be left entire. The operation may be very speedily effected 

in the following manner. Commence 
an incision on the radial side of the 
carpus about half an inch higher than 
the articulation of the metacarpal bone 
with the os trapezium ; direct it at first 
down along the line of the metacarpal 
bone, and afterwards along its external 
aspect to the fold of integument be- 
tween the thumb and forefinger, intro- 
duce the point of the knife at this under 
extremity, carry it up on the palmar 
aspect of the bone, make it emerge at 
the commencement of the incision, and 
make the flap by cutting outwards. 
With one or two further touches of the 
knife the thumb may be detached, and 
after this operation there remains only 
a single line of cicatrix on the radial 
border of the hand. When only the 
metacarpal bone of the thumb is dis- 
eased, and the phalanges are entire, Mr. Fergus#on has recommended 
that the latter should be left and the former only removed. This 
operation is very easily accomplished by making an incision along the 
radial border of the bone, and effecting disarticulation first from the 
phalanx, and afterwards from the os trapezium. I have performed it 
only once, having met with but one instance in which I considered it 
applicable ; and I have no hesitation in saying that the phalanges were 
more useful than any mechanical contrivance would have been. In 
various instances I have removed the whole of the metacarpal bone of a 
finger, except the extremity, which articulates with the proximal pha- 
lanx, and have been much gratified with the results of these operations. 
The first time I performed this operation was in the case of a young 
gentleman, a member of a highly respectable family in this country. 
The metacarpal bone of the middle finger was diseased, but the ball of 
the bone did not seem to be involved, and I therefore determined to 
endeavour to save the finger. The operation was commenced by 
making an incision along the dorsal aspect of the bone, exposing it dis- 
tinctly to view, and then with the bone forceps cutting across the bone 
in a slanting direction just behind its ball, and in such a way as to leave 
the attachment of the transverse ligament entire ; it was then disarticu- 
lated from the carpus ; the soft parts in the part of the hand were not 
interfered with, and the wound healed up leaving only a single cicatrix 
on the back of the hand. The finger is not at all shorter than it ought 
to be, because the ball which supports the first phalanx is kept in its 
proper position. The gentleman is now an officer in the army, and 
exerts as much force with his hand as if an operation had never been 
performed upon it. I have since performed the same operation in 



Fig. 227. From Liston. 



AMPUTATIONS. 



615 



several instances with the same gratifying result, and can confidently 
recommend it for adoption in cases where it is suitable. 

AMPUTATION OF THE FOREARM. 

The preferable situation is the middle of the forearm. No particular 
advantage results from having the stump very long, and besides, the 
tendons in the under third are less convenient structures in the flaps 
than the fleshy parts higher up ; on the other hand, a very short stump 
is less serviceable than one somewhat longer for the application of an 
artificial hand. 

The humeral artery should be commanded by an assistant, the hand 
placed in a state of pronation, and the muscles put into a uniform state of 
extension by an assistant holding and extending the under part of the 
forearm. 

I generally give the preference to Mr. Liston's mode of performing 
this aputation, which consists in making the posterior flap first, and by 
cutting from the skin to the bone — a proceeding which has the advan- 
tage of enabling the surgeon to make the two horns of the semilunar 
flap extend sufficiently towards the radial and ulnar borders of the fore- 
arm to make it easy, after introducing the knife at one corner of this 
flap to transfix in front of the bones, and bring out the knife at the other 
corner. The front flap is made by cutting towards the surface. The 
most elegant way of making the two flaps is to place the edge of the knife 

Fie-. 228. 




against the skin on the posterior aspect; to run it up to the bone making 
a sufficient flap, and with a movement of the knife to extend the incision 
towards the anterior aspect at the radial and ulnar borders, and then 
without raising the knife to introduce it at one edge of the wound, 
transfix, making the knife emerge at the other edge, and by cutting to- 
wards the skin make the anterior flap. Both flaps are thus made without 

Fig. 228. From Liston. 



616 



AMPUTATIONS. 



once raising the knife from the forearm. The knife is then sent round 
and between the bones, and a clearance having been made for the saw, 
the two bones may be sawn at once without altering the position of the 
hand. 

Another mode equally easy is to place the hand midway between pro- 
nation and supination, to take hold of the soft parts on the back of the 
forearm between the forefinger and thumb of the left hand, to draw them 
away from the bones, and then to transfix with the view of forming the 
posterior flap by cutting outwards ; but in transfixing, it is necessary to 
be careful to introduce the knife and to make it emerge as far towards 
the anterior aspect of the forearm as the bones will permit. The poste- 
rior flap is then made by cutting from within outwards. The knife is 
then introduced at one edge of the wound, sent in front of the bones, 
made to emerge at the other edge of the wound, and the anterior flap is 
formed by cutting from the bone towards the skin. The flaps should 
then be kept back, a clearance made for the saw by sending the knife 
round and between the bones, and the amputation completed by sawing 
the bones. In the one mode, the posterior flap is made by cutting from 
without inwards, in the other, from within outwards. 

AMPUTATION OF T*E ARM. 

Chloroform having been administered, the arm removed from the side, 
and the humeral artery compressed by an assistant, the surgeon, placing 
himself so as to be able with his left hand to grasp the bone while it is 
being sawn through, forms a neat round flap in front, and in doing so 
directs the knife so as to leave the humeral artery in the posterior flap ; — 
an assistant raises up the flap, but at this stage it ought not to be re- 
Fig. 229. 




tracted, as that would increase the difficulty of the next step, which is, 
to send the knife speedily behind the bone, and make a posterior flap of 
the same length and form as the anterior. In making these flaps, in- 
stead of carrying the knife parallel to the bone so far, and then cutting 
abruptly outwards, it is better to direct the knife towards the surface, so 



AMPUTATIONS. 617 

as to give a nice rounded form to the surface of each flap. Both flaps 
should then be powerfully retracted, the knife made to revolve round the 
bone so as to clear a space for the saw, and the bone sawn through 

Fig. 230. 




close to the soft parts, the surgeon meanwhile holding it in his left hand ; 
the artery should be secured, and the edges brought together by means 
of a few stitches. 

AMPUTATION AT THE SHOULDER JOINT. 

It would answer no useful purpose to describe the numerous different 
proceedings which have been adopted in the performance of this opera- 
tion. It may be very speedily and easily effected in the following 
manner : — The patient should be placed on a table, with the shoulders 
raised, that on which the operation is to be performed projecting beyond 
the edge of the table. One assistant is required to administer chloro- 
form and watch its effects ; another, to compress the subclavian artery 
where it passes over the first rib ; and when the patient is under 
the influence of chloroform, it is easy to command the artery completely, 
chiefly, I believe, because the patient, not being conscious of any uneasi- 
ness, makes no efforts to move the body, and so the pressure is not 
diverted from the proper part ; a third assistant is ready to raise up the 
upper flap, and to follow the back of the knife so as to compress the 
second flap when the vessels are divided in completing it ; and a fourth 
to hold the arm, and when the arm is removed to tie the arteries as they 
are taken up by the surgeon. In operating on the left side, the surgeon 
should introduce the knife at the posterior border of the axilla, send it 
in front of the bone, and make it emerge at the anterior border of the 
deltoid, about an inch below the point of the acromion process, and by 
cutting from the bone towards the skin, a large flap is made, chiefly of 
the deltoid muscle and integument ; this flap is raised up by an assistant 



618 



AMPUTATIONS. 



and until it is completed, the arm should be kept away from the side, 
but then brought in front of the chest so as to give prominence to the 
head of the bone and the capsular ligament. The knife is next brought 

Fig. 231. 




against the joint, carried through it to the inner side of the bone, as 
here represented, brought down so far by the side of the bone, and 



Fig. 232. 




then made to emerge, completing the flap. The back of the knife should 
be followed by the hand of an assistant ready to grasp the flap con- 
taining the principal artery as soon as the surgeon is about to complete 
the flap. When the knife is fairly in to the joint, the arm should be 
removed from the side, to give freedom to the knife in making the under 
flap. In operating on the right side, the only difference is, that it will 
be found more convenient, in making the upper flap, to introduce the 
knife at the anterior border of the deltoid, about an inch below the 



AMPUTATIONS. 



619 



acromion process, and make it emerge at the posterior border of the 
axilla : in other words, the direction of the knife in making the upper 
flap, when the operation is on the right side, is exactly the reverse of 
its direction when the operation is on the left ; in the former case it is 
made to penetrate at the anterior border of the deltoid, and to emerge 
at the posterior border of the axilla; in the latter it enters at the pos- 
terior border of the axilla, and is brought out at the anterior border of 
the deltoid. 

The axillary artery and other vessels having been tied, the edges of 
the flaps are brought together by a few stitches, and the wound dressed 
in accordance with common principles. 

Another method of amputating at the shoulder joint is, to take hold 
of the deltoid and move it upwards from the bone, to place the edge of 
the knife against the skin at the under extremity of the upper flap, to 
make that flap by cutting from without inwards, then to direct the knife 
against the joint, enter the joint, carry the knife by the inner side, and 
complete the under flap by cutting from the bone to the surface. In 
this method the knife is never raised from the body of the patient from 
the time it touches the skin until the under flap is completed. I have 
not tried this method in the living body, but have often performed the 
amputation in eight or ten seconds by this method, in the dead subject. 

AMPUTATIONS OF THE UNDER EXTREMITY. 



AMPUTATION OF THE TOES. 

For the amputations of Fi s- 28 '- 

the toes, except the great 
toe, at any of their joints, 
the proceedings are the same 
as for the amputations of 
the fingers, except that when 
the whole of the phalanges 
of a toe require to be re- 
moved, the extremity of the 
metatarsal bone should be 
allowed to remain, as it is 
undesirable to diminish un- 
necessarily the breadth of 
the foot. Amputation of 
the great toe is frequently 
required for disease of its 
metatarsal bone, and it may 
be very easily and quickly 
performed by either of the 
following methods : 

First Method. — Com- 
mence the first incision at 
the upper part of the proxi- 
mal extremity of the metatarsal bone and on its tibial aspect, carry 

Fig. 233. After Liston. 




620 



AMPUTATIONS. 



it forward to the distal extremity, direct it along the inner side of the 
joint to the plantar aspect of the foot, and extend it backwards to the 
part opposite to its commencement. This flap having been directed 
back, send the knife between the bones and cut outwards through the 
commissure between the first and second toes. By a touch or two of 
the knife the metacarpal bone may then be separated from the internal 
cuneiform. The operation is exceedingly simple by this method, and 
the result generally very satisfactory. 

Second Method. — Commence the incision about half an inch behind the 
proximal extremity of the metatarsal bone, and continue it forwards to 
about the middle of the bone, and then make it divide into two, meeting 
each other on the plantar aspect of the digital commissure. Detach the 
soft parts from the bone, and then disarticulate from the internal cunei- 
form. This is an excellent mode of performing the operation, and I 
generally give it the preference. It leaves only a single line of cicatrix 
along the inner part of the foot. The same operation answers when it is 
unnecessary to remove the whole of the metatarsal bone, the only modi- 
fications being that it is not requisite to carry the incision so far back, 
and the bone has to be cut by the bone forceps, — in doing which it is 
advisable to cut in a slanting instead of a transverse direction, as the 
alteration of the outline of the foot on its inner side is thus rendered 
less abrupt, and the part consequently less exposed to be irritated by 
pressure. 

AMPUTATION OF THE FOOT. 

Hey 8 Operation. — This consists m performing amputation between 
the tarsal and metatarsal bones ; and of the many methods adopted for 
its performance, I think the following the preferable. The leg having 

been firmly placed on a table, 
Fig. 234. beyond the edge of which the 

foot projects, and being secured 
in its position by an assistant, 
the surgeon takes hold of the fore 
part of the foot with the left 
hand, and having made sure of 
the extremities of the metatar- 
sal bones of the great and little 
toes, if the operation be on the 
right foot, he inserts the knife on 
the edge of the foot a little behind 
the prominence of the metatarsal 
bone of the little toe, carries it 
directly forward on the edge of 
the foot for nearly an inch, directs 
it in a semilunar manner on the 
dorsum of the foot to the base of 
the metatarsal bone of the great 
toe, and then carries it back for 
nearly an inch on the inner edge of the foot. The parts should be cut 
through boldly down to the bone, and the short flap brought back, and the 

[Fig. 234. From Skey.— Ed.] 




AMPUTATIONS. 621 

situation of the tarso-metatarsal articulations exposed. The knife is next 
introduced at the extremity of the incision on the inner edge of the 
foot, sent underneath the bones, and made to emerge at the outer edge 
of the foot at the commencement of the first incision, and a long flap is 
made from the sole of the foot, sufficiently long to cover the ends of the 
bones and to unite with the short flap on the upper part of the foot. 
The surgeon then presses heavily on the forepart of the foot, so as to 
make it more easy to send the point of the knife into the articulations 
between the bones ; and this having been done, the operation is speedily 
completed. The long flap covers the extremities of the bones, and a 
single cicatrix along the upper part of the stump is the only permanent 
mark of the operation. 

This is generally a very satisfactory operation in cases for which it is 
suitable. The only differences to be observed when the operation is on 
the left foot are, 1st, that it is more convenient in making the first in- 
cision to commence behind the base of the metatarsal bone of the great 
toe, and to make it terminate behind that of the little toe ; and, 2d, 
that in transfixing to make the long flap below, it is- more convenient to 
insert the knife at the outer, and to make it emerge at the inner edge of 
the foot. 

In performing this operation an elegant proceeding is, after making 
the upper flap, to transfix without raising the knife from the foot, so 
that the upper and under flaps are made by one continued movement of 
the knife. 

Chopart's Operation. — This operation, improved by modern surgeons, 
retains the name of Chopart, who first performed it. It consists in per- 
forming amputation at the medio-tarsal articulation, or, in other words, 
at the articulation formed by the astragalus and calcaneum behind, and 
the scaphoid and cuboid bones in front, the astragalus and calcaneum 

Fig. 235. 




being the only two bones that are left. The site of the articulation is 
first sought for, and the best guides for finding it are the projection of 
the scaphoid bone on the inner side, immediately behind which is the 
articulation, and the projection of the base of the fifth metatarsal bone 
on the outer edge of the foot, about half an inch behind which projec- 
tion, and about midway between it and the anterior part of the malleolus 

[Fig. 235. From Druitt.— Ed.] 



622 AMPUTATIONS. 

extemus is the outer part of the articulation. These guides having been 
found, a short flap is formed above and a long one below, and the pro- 
ceeding is in all respects similar to that in Hey's operation, except 
that the incisions are commenced further back, namely, about half an 
inch behind the guides already mentioned on the margins of the foot. 

Relative Merits of the two last-described Operations. — In Hey's opera- 
tion, the anterior lever of the foot remains longer than the posterior ; 
and the tendons of the extensor muscles contract adhesions to the upper 
part of the foot, which, aided by the insertion of the tibialis anticus 
muscle, prevent the drawing up of the heel, and consequently there is 
no danger of the front of the stump being pressed against the ground. 
In all cases which have come under my observation, the result of this 
operation has been all that could be reasonably expected or desired. 
Perfect candour requires me to express a different opinion regarding 
Chopart's operation. Although both in one case in which I performed 
this operation some years ago, and in another in which another surgeon 
operated, I am aware that the attitude of the stump has remained most 
satisfactory, and the patients can walk with perfect ease, yet, in a third 
case, in which I again operated, and in which every possible care was 
taken to maintain a proper attitude of the stump, the preponderating 
action of the muscles of the calf of the leg was not counteracted by ad- 
hesions of the tendons in front to the cicatrix or other structures ; and 
consequently, the heel was drawn up and the cicatrix made to project 
against the ground in attempts at walking — an untoward result too 
common in'the experience of surgeons. 

The occurrence of this circumstance where the greatest possible care, 
as far as attitude was concerned, was taken to prevent it, has given me 
an unfavourable opinion of this operation, and I should not hesitate, 
therefore, in future, after candidly explaining to a patient the probable 
results of it compared with amputation at the ankle-joint, to express a 
decided preference in favour of the latter, which is so very satisfactory 
in cases for which it is suitable. It is the duty of every one to give the 
result of his own experience, and I have therefore stated very unre- 
servedly the conclusion at which I have arrived regarding Chopart's 
operation. It is true that it is exceedingly easy to be performed, much 
more so than that of Hey, because the articulation is much more open, 
and therefore much more easily entered ; but this is comparatively a 
small matter, it being the ultimate result that demands the serious con- 
sideration of the surgeon who has to advise regarding the welfare of his 
patient. 

AMPUTATION AT THE ANKLE-JOINT. 

The following are Professor Syme's directions for the performance of 
this amputation. — " The foot being placed at a right angle to the leg, a 
line drawn from the centre of one malleolus to that of the other directly 
across the sole of the foot will show the proper extent of the posterior 
flap ; the knife should be entered close up to the fibular malleolus, and 
carried to a point on the same level on the opposite side, which will be 
a little below the tibial malleolus ; the anterior incisions should join the 
two points just mentioned at an angle of 45° to the sole of the foot, and 
long axis of the leg. In dissecting the posterior flap, the operator should 



AMPUTATIONS. 623 

place the fingers of his left hand upon the heel, while the thumb rests 
upon the edge of the integuments, and then cut between the nail of the 
thumb and the tuberosity of the os calcis, so as to avoid lacerating the 
soft parts, which he at the same time gently, but steadily, presses back, 
until he exposes and divides the tendo Achillis. The foot should be 
disarticulated before the malleolar projections are removed, which it is 
always proper to do, and which may be most easily effected by passing 
a knife round the exposed extremities of the bones, and then sawing off 
a slice of the tibia connecting the two processes." In performing this 




operation I have followed the above directions with the exception of 
those contained in the last sentence. Instead of disarticulating the 
foot, and then sawing off the malleolar processes and a thin slice of the 
tibia connecting them with each other, I have, after making a clearance 
for the saw by sending the knife round the bones, sawn off the malleolar 
processes and a very thin slice of the tibia, without effecting disarticula- 
tion. This shortens the proceeding, and whenever I have performed 
this operation, nothing could be more satisfactory than its results. The 
operation according to this method is exceedingly easy to be performed, 
and some of the many advantages of this amputation are, that the soft 
parts of the heel thus furnish an admirable cushion for a covering to the 
bones, that the stump is in consequence excellently adapted both for 
bearing the superincumbent weight, and for progessive motion — a re- 
commendation which the method of making the flap from the heel pos- 
sesses over all the other modes which have been proposed — and that the 
cicatrix which presents a single line, is in front of ^he stump, and there- 
fore escapes the direct pressure of the superincumbent weight in walk- 
ing. Patients can, in most instances, very soon bear the superincumbent 
weight on the stump, and with an artificial foot into which the rounded 
stump is introduced, they can walk easily and not very ungracefully. 
In bringing back the posterior flap over the calcaneum the greatest care 
must be taken not to use any violence by which its vitality might be en- 
dangered, and a risk induced of its sloughing after the operation. 
So favourable are my impressions of this operation, and of the above 

[Fig. 23G. From Fergusson. — En.] 



624 AMPUTATIONS. 

mode of performing it, that I deem it unnecessary to detail the many 
different methods which have been proposed since the introduction of 
this operation into the practice of the surgeons of this country. I think 
it proper, however, to add, that of the cases of disease of the bones of 
the foot, and of the ankle joint, which have come under my own obser- 
vation, both public and private, and that of some of my colleagues at 
the Infirmary, there have been much fewer in which this operation 
would have been suitable, than I at one time anticipated from the state- 
ments of others. t I have been much struck with the fact that, in a great 
number of the cases which came under our notice, there have been, 
together with disease of the bones of the foot, abscesses in the under 
extremities of the bones of the leg. This is a point to which my atten- 
tion has been particularly directed since the advantages of amputation 
at the ankle joint have been thoroughly appreciated ; and while I think 
this operation an admirable one for a certain class of cases, I see no 
prospect of its superseding amputation in the under part of the leg. 

AMPUTATION OF THE LEG. 

An excellent and speedy mode of performing this operation, and that 
which I have usually adopted, is the following : — The circulation being 
commanded by pressure on the femoral artery, the surgeon being placed 
on the left side of the patient, applies the knife near its heel to the right 
side of the leg, and draws it across to the left side in a semilunar direc- 
tian, so as to form a short anterior flap, and then without raising the 
knife transfixes the leg, the knife entering and emerging at the extre- 
mities of the first incision, and a long posterior flap being formed by 
cutting from the bones to the surface. The soft parts between the bones 
underneath may be cut before the knife is brought to the front of the 
leg, and then by a few touches the short flap in front is brought back, 
the soft parts between the bones divided, and a clearance made for the 

Fig. 237. 




saw. The surgeon being on the left side of the patient is able to hold 
the bones with his left hand during the movements of the saw. The 
projecting angle of the tibia should be removed by the saw or bone- 
forceps, that it may not irritate the integument over it. 



AMPUTATIONS. 625 

Another and a very easy method is to form the posterior flap in the 
first instance ; and with that view the operation is commenced by trans- 
fixing the leg. The points of transfixion are then connected together 
by a semicircular movement of the knife across the front of the leg, and 
the flaps having been turned back and the bones cleared by carrying the 
knife around and between them a little above the points of transfixion, 
the amputation is completed by sawing the bones. The accompanying 
illustrations will make this operation perfectly intelligible. 

I quite concur with Professor Lawrie of Glasgow in all that he has 
done to produce a favourable impression of this operation, and also in 
what he has said as to the facility with which patients walk with an 
artificial limb into which the leg is fixed with the knee straight. Many 
of my patients walk with perfect ease with an artificial leg and foot, 
and without any appearance of mutilation or deformity. I have made 
it a point to leave the stump as long as possible, and have seen no reason 
to be otherwise than satisfied with the proceeding. Having been in the 
habit of amputating at all parts, as far down as the commencement of 
the inferior third of the leg, I am enabled to bear my testimony to the 
advantage of the proceeding. As a proof of the facility with which 
patients walk after this operation, I may state that a man, both of whose 
legs I amputated at the commencement of the inferior fourth, in the 
Aberdeen Royal Infirmary, on account of gangrene, walks very well 
on two artificial legs and feet which I gave to him after the stumps were 
in a fit state to be introduced into them ; they were made by a surgical 
mechanist in Aberdeen. From my own experience, and that of my 
colleagues, I should be exceedingly sorry to see this operation abandoned 
for one that involves more mutilation of the body. 

AMPUTATION OP THE THIGH. 

The patient having been properly placed, the artery compressed by 
a trustworthy assistant, and the leg held in the proper position by 
another assistant, the surgeon, if the operation be on the left thigh, 
stands on the fibular side of the limb, and having taken hold of the soft 
parts in front of the bone with his left hand, raises them a little, and 
performs transfixion by introducing the knife on the outer side, carrying 
it across in front of the bone, and making it emerge on the inner side, 
and then forms the anterior flap by cutting towards the surface. An 
assistant then simply holds up the flap without retracting it at this stage, 
and the surgeon sends the knife behind the bone about an inch lower 
than the commencement of the first incision. The advantage of ob- 
serving these two directions is, that the knife is more readily sent 
behind the bone without touching the skin on either side. The knife is 
then brought to the surface in the direction represented by the dotted 
line in the accompanying engraving, and by this movement the posterior 
flap is formed. This flap should be a little longer than the anterior to 
compensate for the greater retraction which takes place in it, owing to 
its muscles having less connexion with the bone than those of the 
anterior flap. An assistant retracts both flaps very forcibly, and the 
surgeon makes the knife revolve round the bone so as to effect a clear- 
ance for the saw. He then grasps the bone in his left hand, and saws 

40 



626 



AMPUTATIONS. 



it through, close to the soft parts, moving the saw in a vertical direction. 
The only differences in operating on the right thigh are that the surgeon 

Fig. 238. 




stands on the tibial side, and introduces the knife on this, instead of the 
fibular aspect. If, however, in this case there be the least prospect 

Fig. 239. 




that his standing on the tibial side may cause an awkwardness or want 
of proper freedom for making the necessary movements of the knife, the 



AMPUTATIONS. 



627 



operation can be performed with perfect facility and convenience when 
standing on the other side ; only the bone, while it is being sawn, can- 
not then be conveniently held by the left hand of the surgeon. 

AMPUTATION OF THE HIP-JOINT. 

The cases in which it is necessary to resort to this operation are not 
numerous ; and this is fortunate, for although a sufficient number of 
successful cases are on record to make it perfectly justifiable on the part 
of the surgeon to resort to it in extreme circumstances, yet it is proved 
beyond doubt, that as regards ultimate consequences, it is an exceed- 
ingly perilous proceeding ; though there is no difficulty in executing the 
operation, and it can be performed in the living body with great ease 
in less than twenty seconds. In the only instance in which I have per- 
formed it in the living body, and often when I have performed it in 
the dead body before my class, the operation has not . occupied even 
so much time. I mention this merely to show that there is no 
difficulty in performing it. The following observation of Mr. Liston 
should be strongly kept in view: — " These operations must be under- 
taken with determination, and completed rapidly, in order that danger- 
ous effusion of blood may be prevented ; they are not to be attempted 
without great consideration, and only under very pressing circum- 
stances." From much practice in performing this operation on the 
dead body, I have arrived at the conclusion that Mr. Liston' s method is 
preferable to any other. He commenced transfixing by introducing the 
knife midway between the anterior superior spinous process of the ilium 
and the trochanter major of the femur. The following description and 
illustration, taken from his admirable work on Practical Surgery, will 
make his method perfectly intelligible : — " By forming the flaps from 
the anterior and posterior aspects of the limb, the bone may be exposed 

Fig. 240. 




and sawn at the inner trochanter, or it may be removed at the joint. 
In making the incision thus high, the common femoral is compressed, 
as it passes over the brim of the pelvis, and an assistant must follow the 
knife with his hand, and grasp firmly the anterior flap, whilst others 



628 RESECTIONS. 

are ready to compress those of the posterior as soon as the sawing, or 
disarticulation, is completed. This mode of getting at the head and 
neck of the bone is much preferable to that usually followed, and is in 
every respect safer, as I have more than once ascertained from actual 
practice on the living body. The fore-part of the articulation is fully 
exposed immediately on the anterior flap being formed. The capsular 
ligament is cut by drawing the knife across determinedly, as if it were 
the intention of the operator to cut off the head of the bone. The round 
ligament and posterior portion of the capsular are cut, and the blade of 
the instrument having been passed behind the neck and trochanters, the 
posterior flap is quickly formed, so as to allow the limb to drop. The 
vessels on the posterior aspect are first tied, then the femoral and those 
in the anterior flap, which has been commanded by the assistant, are un- 
covered one by one and secured." 

AMPUTATION OF THE PENIS. 

The part to be removed is covered with some lint, laid hold of by the 
left hand, put upon the stretch, and then removed by one stroke of a 
long knife moved rapidly across the organ. Such vessels as require 
ligature having been secured, the surgeon lays hold of the mucous mem- 
brane of the urethra by means of a forceps, and divides it into four 
equal flaps, by four cuts with a pair of scissors, and then by four small 
sutures of fine thread unites each flap to the common integument. The 
skin and mucous membrane unite together, and the contraction of the 
cicatrix has the effect of keeping the urethra open and of sufficient 
calibre. 

RESECTIONS. 

Under this title are comprehended the removal of the articular extre- 
mities of bones — in other words, excision of joints — the resection of long 
bones to their continuity, and the partial or entire removal of certain 
bones. One of the earliest, if not the first operation actually performed 
of this kind on record, is excision of the knee-joint, by Filkin of Liver- 
pool, in 1762. Very soon after this, Vigaroux and David removed the 
head of the humerus, but their operations were not published until after 
the upper part of the same bone had been removed by White of Man- 
chester, in 1768, to whose operations we shall afterwards have occasion 
to refer. The gratifying results which, in the experience of many sur- 
geons in this and other countries, have followed the excision of joints, 
have contradicted many of the objections urged against these operations ; 
they have proved that many limbs may be preserved, and in a state to 
be ultimately useful, which would otherwise have been subjected to am- 
putation ; and have contributed much also to diminish the number of 
amputations for diseased joints of the upper extremities. To Professor 
Syme, too great praise cannot be awarded for his successful exertions in 
this department. It may be stated that the two joints on which these 
operations have been most successfully practised, are the shoulder and 
elbow joints ; in the ankle it is of very doubtful advantage, and in the 
knee, hip, and wrist joints, the want of success has been unquestionably 
great, — so great indeed in the knee and hip, that the present state of 



RESECTIONS. 629 

experience appears to suggest the propriety of avoiding resection in these 
joints, except in the case of injuries. 

PARTICULAR RESECTIONS. 
RESECTION OF THE SHOULDER-. J 01 NT. 

The many different methods which have been adopted for this opera- 
tion may be almost all reduced to one or other of two principal methods, 
namely, that in which the bone to be removed is exposed by making a 
flap, and that in which it is exposed by means of a simple incision. Of 
these two methods it may be stated generally, that while the latter is 
sufficient when the operation is performed for the purpose of removing 
the crushed head of the bone, yet in most cases where it is employed for 
the removal of diseased bone, the former will be found the preferable 
proceeding. The directions for the performance of the operation by 
means of a flap are very simple : — make a vertical incision from the 
apex of the acromion along the middle of the deltoid to near its inser- 
tion, and from the under extremity of this incision make another upwards 
and backwards, cutting in a semilunar direction towards the posterior 
border of the axilla ; raise up the flap, which will comprehend the ex- 
ternal portion of the deltoid ; open the joint ; detach the muscles which 
are inserted into the tuberosities ; thrust out the head of the bone, and 
saw it through, carefully guarding against injuring the soft parts.- Such 
is the method practised by Professor Syme. It would answer no useful 
purpose to describe the different varieties as to the forms of flap recom- 
mended by many other surgeons. White of Manchester, Orred of Ches- 
ter, Larrey, Sir Charles Bell, and some others exposed the bone by a 
single longitudinal incision extending from the upper part of the shoulder 
to near the insertion of the deltoid. Jaeger gives a collection of fifty- 
three cases of excision at the shoulder-joint, of which large number he 
states that only two had an unfavourable result. With the exception of 
the case of Edmund Pollit, operated upon by Mr. White in the Manches- 
ter Infirmary, on the 6th of April, 1768, there has uniformly been a 
degree of shortening proportioned to the extent of bone removed. In 
the case referred to, although nearly four inches of the bone were 
taken away, the arm was very little shortened, and the form of it 
little altered : the rotatory and other movements and the use of the 
joint became complete, and the part from whence the bone was taken 
soon acquired a considerable degree of firmness. These and other con- 
siderations have led some to conclude, and so far as one can judge, 
rightly, that this interesting case was not one of caries, but acute ne- 
crosis, in which the head of the bone was not removed by the operation, 
but detached from the upper part of the shaft by disease, and became 
united to the regenerated shaft after the removal of the part which had 
been affected with necrosis. In Professor Syme's valuable contributions 
to the Pathology .and Practice of Surgery will be found some very inte- 
resting observations on this case by White, which, whatever was the real 
nature of the disease for which the operation was performed, has, in a 
great measure, "led the way to all that has been done in this depart- 
ment of surgery." 



630 RESECTIONS. 



RESECTION OF THE ELBOW-JOINT. 



Mr. Park of Liverpool published a work in 1783, in which he proposed 
to open the knee and elbow-joints, and to saw off the extremities of the 
bones entering into their formation, when in a carious state. Falkin of 
Liverpool had, as early as 1762, performed the operation on the knee ; 
and the celebrated Moreau, following the suggestion of Park, was the 
first to perform the operation on the elbow-joint. The mode of perform- 
ing it which he devised and adopted, with a very slight modification, is 
upon the whole the best. Sir Philip Crampton performed this opera- 
tion in February, 1823 ; and in 1829, Professor Syme gave, in the 
"Medical and Surgical Journal," an account of three cases. Since 
that time, most good surgeons have resorted to it in preference to ampu- 
tation in cases in which it appeared suitable. In Jaeger's collection of 
cases of this operation it is stated that, out of thirty-four, only four had 
an unfavourable result. The conditions in which amputation is to be 
preferred to excision are, when the strength of the patient is so much 
diminished as to make it doubtful whether he could bear a protracted 
discharge, and when the disease is supposed to extend beyond the arti- 
culating extremities of the bones. 

The operation may be performed in the following manner : — The 
patient having been placed in the prone position with the elbow semi- 
flexed resting on the edge of a table, and presenting its posterior aspect 
to the surgeon, the joint is conveniently exposed by a wound in form 
resembling the letter H. The parallel portions of the wound may be 
two inches long, and the transverse portion should extend from the very 
margin of the outer tuberosity of the humerus along the upper part of 
the olecranon process to as near the inner tuberosity as may be without 
endangering the ulnar nerve. For the purpose of avoiding the ulnar 
nerve, it has been suggested to thrust down the knife perpendicularly 
into the joint with its back directed towards the nerve, and then to make 
the transverse incision by cutting towards the external tuberosity. The 
two square-shaped flaps having been detached from the subjacent parts, 
and the bones brought into view, the olecranon process should be cut 
through with the bone forceps, and the lateral ligaments divided. After 
which the humerus can easily be made to protrude, and be sawn off 
through* the tuberosities. The head of the radius, and the portion of 
the sigmoid cavity of the ulna left after the division of the olecranon 
process, should be removed by the bone forceps or saw, and bleeding 
having been arrested, the edges of the wound should be brought together, 
and the arm secured in a semi-flexed position. A most useful joint 
formed by ligamentous union is the usual result. 

Resection of the wrist-joint is not found to succeed, and therefore 
when diseases of that articulation prove incurable, amputation is the 
advisable proceeding. Resection of the ankle joint in cases of disease 
is of doubtful propriety, it being questionable whether the best results 
of that operation are so useful or satisfactory to the patient as an arti- 
ficial foot after amputation at the ankle joint. And with regard to 
resection of the knee and hip joints, so large a proportion of the cases 
hitherto recorded have terminated fatally, and so very few have been 



REMOVAL OF THE UPPER JAW. 631 

attended with a favourable result, that it has now become pretty clear 
that they are hardly admissible into the list of justifiable operations, 
except in the instances of gunshot wounds, or other injuries of the bones 
forming these articulations. It is therefore deemed unnecessary to give 
the statistics of these operations, or to describe the mode of their per- 
formance. 

REMOVAL OF THE UPPER JAW. 

That it may be more clearly seen to whom belongs the merit of first 
proposing the removal of the whole of the upper jaw, the operations on 
this bone may be arranged into two classes, namely, those which con- 
sisted in scooping out the contents of the antrum, and more or less of 
the surrounding parts, and those which consisted in the entire removal 
of the jaw. 

The first recorded operation belonging to the former of these two 
classes was performed by Akoluthus, a physician of Breslau, in 1693, 
on a female who had a tumour in her jaw ; this he succeeded in removing 
partly by cutting, and partly by the actual cautery, performing the 
successive steps of the operation at intervals of some days. Various 
operations of this kind were performed by Desault, by Jourdain, by 
Dupuytren, and others. One performed by Dupuytren in 1819, brought 
this kind of proceeding very much into notice, and since that time it has 
not been unfrequent. One of the most remarkable examples on record 
is an operation performed by Dr. Thomas White ; remarkable not less 
on account of the recovery of the patient than for the extent of parts 
removed ; most of the jaw was no doubt removed in this case, partly by 
caustic, partly by scooping, and partly by the actual cautery. 

As to the second of these two classes of operations, to Professor John 
Lizars of Edinburgh unquestionably belongs the merit of having first 
proposed the removal of the entire jaw. He made that proposal in 1826, 
and suggested that the carotid artery should first be tied. He attempted 
his first operation in December, 1827, but was obliged to abandon it 
without succeeding, on account of hemorrhage. The patient, who was a 
collier, lived seventeen months after the attempt. His second operation 
was performed on the 1st of August, 1829. The wound was healed on 
the sixteenth day and the patient left the hospital, but died suddenly 
three days after her dismissal. In this case the temporal and internal 
maxillary arteries, and the external jugular vein which had been divided 
were tied. His third operation was performed on the 10th of January, 
1830 ; the external carotid was first tied ; on the 5th of March the woman 
was able to leave the hospital. 

Gensoul of Lyons, in May, 1827, performed this operation with success 
on a young man seventeen years of age, and he states that he was 
not aware of Professor John Lizars having proposed the operation ; he 
did not adopt the proceeding of first tying the carotid artery. It ap- 
pears then that Professor John Lizars was the first that proposed, and 
that Gensoul, without the knowledge of his proposal, was the first 
that performed this operation. 

Of the many methods adopted in the performance of it, that of Syme 
appears to be the best. After the removal of one of the central incisors, 



632 



RESECTION OF THE LOWER JAW. 



two incisions are made, one from the inner angle of the eye to the lip, 
and the other from the junction of the malar and maxillary bones to the 
angle of the mouth ; and the flap is dissected up to the margin of the 
orbit. The nasal process is then divided by a pair of strong cutting 
pliers, one blade being introduced into the orbit and the other into the 
nose ; by the same instrument it is separated from the malar bone ; the 
palatine arch is next clipped through; the bone is then pushed down 
and detached, care being taken to preserve, if possible, the palatine 
process of the palate bone and the velum palati. It is quite unnecessary 
to tie the carotid artery, but pressure on it on one side should be em- 
ployed, while the bone is being depressed and removed. 

RESECTION OF THE LOWER JAW. 

The following case of resection of the lower jaw performed by me in 
1840, appeared with the accompanying illustration in the "Edinburgh 
Medical and Surgical Journal," for July, 1840. 

In the end of November, 1839, Thomas Grant, aged nineteen years, 
applied to me under the following circumstances. 

The left side of the lower jaw from near the symphysis to the angle 
was diseased, and so extensively enlarged as not only to produce great 
swelling and deformity of the face, but also by pressing inwards upon 
the tongue, considerably to impede its movements. The diseased portion 



Fig. 241. 



Fig. 242. 





of bone also hung down upon the upper part of the neck, and extended 
considerably backwards. The soft parts of the cheek and upper region 
of the neck were very much inflamed, giving rise to diffuse swelling ; 
and two abscesses had burst over the middle of the diseased portion of 
the bone. The pain in the bone was at times most excruciating. He in- 
formed me that the disease had commenced about three years previously, 



RESECTION OF THE LOWER JAW. 633 

when it was supposed to arise from the irritation caused by a carious 
tooth, which was at the time extracted without affording him any allevi- 
ation of his sufferings. From the nature of the case it was evident that 
excision of the diseased portion of bone was the only remedy ; and 
several of my professional brethren, well qualified to judge, were decided 
as to the necessity of such an operation. With the assistance of Dr. 
Fowler, now of Corstorphine, and of my senior pupil, the operation was 
performed on the 15th of February, 1840, in the following manner. 

I commenced my first incision at the middle of the lower lip and ex- 
tended it downwards over the middle of the chin, to a little below the 
margin of the diseased bone. From the termination of that incision, I 
ran the scalpel along the entire inferior border of the bone, turning up 
behind the angle and ending about midway between it and the condyloid 
process. The extensive flap contained within those incisions was next 
dissected up, and laid upon the upper part of the face, so as fully to 
expose the diseased portion of the bone. 
The jaw was then sawn through, imme- Fi S- 243 - 

diately at the left side of the symphysis, 
and afterwards obliquely through the as- 
cending ramus, opposite the last molar 
tooth, particular care being taken to pro- 
tect the vessels by pressing them inwards. 
The section of jaw was then carefully re- 
lieved from its internal soft attachments 

by drawing the knife along its internal surface, keeping its edge close 
upon the bone. The diseased soft parts connected with the openings of 
two abscesses on the cheek, and some diseased tissues in the upper region 
of the neck were then cut out, and after suppressing the hemorrhage, 
which was excessive, the flap was brought down, and by means of a few 
stitches and adhesive plaster the edges of the wound were kept in appo- 
sition. 

About four weeks afterwards, on the 14th of March, union was en- 
tirely effected, leaving so little external deformity as to show very slight 
traces of such an operation. 

The mode of performing resection of the lower jaw must vary accord- 
ing to the situation and size of the tumour, and the extent of the part 
to be removed. 

Figs. 241, 242, 243. Drawings of case referred to in the text. 




634 



CHAPTER XIX. 

DELIGATION OF ARTERIES. 

The deligation of an artery is performed in order to obliterate its 
canal, and stop its circulation at that point ; to arrest hemorrhage from 
itself, or from some of its ramifications, when wounded or otherwise laid 
open ; or, to divert the chief current of blood from a diseased portion 
of the same trunk, or of one of its branches, as in the operation for 
aneurism. If the object be to arrest hemorrhage, the vessel is, when 
possible, exposed at the seat of injury : and two ligatures are applied, 
one above, and the other below the point of lesion. Deligation of the 
main trunk on the cardiac aspect of the injury would suspend the flow 
of blood from the proximal orifice of a divided artery, though probably 
not from the distal, or from a puncture in an artery not completely cut 
through, owing to the free anastomosis supplying blood to the main 
channel at some little distance below the point at which circulation has 
been arrested by the ligature. This is especially the case in the arte- 
ries of the extremities, the ramifications of which form very numerous 
inosculations. The only safe rule of practice, therefore, is to accom- 
plish deligation both above and below the seat of injury. 

When the object is to suspend or weaken the current through an 
aneurism, the vessel is to be exposed, and the ligature applied at some 
spot on the cardiac aspect of the lesion, but not so near as to endanger 
the deligation of a diseased portion of the vessel, or, on the other hand, 
so distant from it as to permit the collateral circulation to supply blood 
to the aneurism, except in very much diminished quantity. The liga- 
ture must also be applied at a point where no large branch proceeds 
from the vessel either above or below; so that space may be allowed for 
the formation of an efficient coagulum. It must be small, round, smooth, 
and firm, so as to effect clean division of the inner and middle coats of 
the artery, yet without laceration of the external tunic ; and it must be 
strong, so that it may be pulled tightly without breaking. 

When an artery is completely divided in a wound, each extremity is 
to be seized by the spring forceps or tenaculum, and drawn out, isolated 
from the surrounding tissues, to a sufficient extent to permit the ligature 
to be cast round it. At the same time, care is to be taken to exclude 
veins and nerves, as also portions of muscular tissue, which would pre- 
vent the ligature from embracing the arterial tunics with accuracy, or 
from effecting the necessary division of their inner layers ; while they 
would, by speedy absorption or sloughing, relax the noose, endanger its 
slipping, and so give rise to secondary hemorrhage. The ligature is 



DELIGATION OF ARTERIES. 635 

always to be tied with precision in the form commonly called the reef- 
knot, which is drawn as tightly as possible, there being no danger of 
dividing the cellular coat of the vessel. 

For tying an artery in its continuity, the instruments generally re- 
quired are, two or three sharp scalpels of different sizes ; a pair of good 
dissecting forceps ; two or three flexible copper spatulse, about an inch 
in breadth ; and an aneurismal needle, of curve varying according to 
the vessel requiring operation, and provided with a small round aper- 
ture near its point, just large enough to transmit the ligature, with 
which it is to be armed before commencing the operation. The point 
of this needle must be so far blunt as to be in no danger of piercing 
the arterial or venous coats, yet not to such a degree as to require 
much force to send it through the lax cellular tissue surrounding them. 
There should be spare silk at hand, a few suture needles, and isinglass 
plaster, besides the usual accompaniments of surgical operations — 
sponges, lint, and water. It is proper also to have a pair of spring 
forceps, lest any small vessel be divided during the dissection. It is 
better to avoid the use of the director in the division of the layers, as 
this instrument always causes more or less bruising of the parts. 

The patient is placed in a position suitable for obligation of the par- 
ticular artery. During the first incision, the posture should be so 
managed as to make the skin somewhat tense in the proposed line of 
wound, as this facilitates the perception of the guides to the vessel, and 
permits a smooth division of the integuments. Subsequently, however, 
relaxation is advisable, in order to allow of nerves and veins being 
drawn aside, and to facilitate the easy passage of the needle. The 
guides to the artery are examined, and its course is traced by its pulsa- 
tion, when this is perceptible on the surface. An incision of ample 
length is then made over the vessel, nearly in a line with its course, so 
as to obtain the full room afforded by the length of the wound ; but 
sometimes a slight obliquity of direction is useful in facilitating the dis- 
covery of an intermuscular space, when the dissection is to be prose- 
cuted deeply. The knife should not cut more than the integument and 
subcutaneous cellular tissue at this first stroke, whether the artery be 
deep or superficial. In the latter case, a slight excess in depth might 
lead to wounding the vessel ; and in the former, muscular fibres might 
be cut, the blood from which would obscure the farther dissection. Su- 
perficial veins and nerves are avoided in this incision, when their course 
is seen or known. The margins of the cutaneous wound are drawn in 
apart, and the deep fascia divided along the yellow line marking the 
muscular interspace, when this is the farther course of the dissection ; 
or it is cautiously pinched up with a dissecting forceps, and divided in 
the requisite direction and extent by the surgeon lateralizing the cutting 
edge of the knife towards himself, when the vessel is superficial. 

This motion of the knife is by far the safest ; and when other things 
permit, the operator should stand on that side of the patient, which 
will enable him to lateralize the knife at the same time, away from 
the chief vein or nerve that is most in danger of injury. By thus 
keeping as much as possible the flat surface of the knife directed to the 
artery, and its back towards the vein or nerve, any accidental slip will 



636 DELIGATION OF ARTERIES. 

be less apt to injure either. In deep dissections, the sides of the wound 
are kept apart by the copper retractors, bent to the required form. 
These take up much less room than the fingers of an assistant, and 
by exerting pressure assist in preventing venous oozing. Veins are 
avoided or drawn aside if necessary, as, when wounded, the blood 
which they furnish seriously obscures the most delicate part of the 
operation. 

As the dissection deepens, a sponge or piece of lint is employed to 
remove any blood, which interferes with a distinct view of the parts, 
and nerves are gently drawn aside when in the way. The sheath of 
the vessels, being at last reached, is pinched up and opened in'the same 
cautious manner as already described, to the extent of half an inch in 
front and over the artery rather than above the vein, which, if large, 
might overlap and obscure the former. Any loose cellular tissue now 
found covering the artery must be directed by the gentle touches of the 
scalpel, until the coats of the vessels are seen distinct and white, and 
sufficiently exposed in front, to permit the insinuation of the point of 
the aneurismal needle between them and surrounding objects; while all 
farther separation or disturbance is effected merely by the track of the 
needle in making its way round. The artery is by no means to be ex- 
posed to a greater extent than this, and must not be rudely lifted up in 
passing the armed needle. The point of this instrument should be 
entered on that side of the artery, on which there is the greater risk 
of including nerve or vein ; because at first it can be applied close to 
the artery with greater exactness than can perhaps be maintained during 
the rest of its course. Being applied at the proper side, and in close 
contact with the vessel, the point is insinuated between it and the ad- 
jacent object, with a gentle lateral motion of the handle, and is after- 
wards carried round by making the free extremity of the latter describe 
part of a circle, of which the artery represents the centre. When the 
point of the needle, having completed the circuit, is felt by the finger 
to be partially covered with cellular substance, the latter is to be cleared 
off by a touch with the nail or scalpel. The point being brought into 
view, the loop of the ligature is then seized with the forceps, drawn 
through a little and detained, while the needle is gently withdrawn ; 
after which the loop is cut, and one portion of the ligature removed. 
The single thread now remaining is tied as firmly as possible in the 
reef-knot. One end being allowed to remain, it is brought out at the 
most convenient part of the wound, which is to be drawn together, 
secured by isinglass plaster or suture, and treated for adhesion. A 
piece of plaster should be applied over the extremity of the ligature 
which hangs from the wound, so as to prevent its catching anything 
that might endanger its forcible withdrawal. 

Throughout the whole operation, the utmost delicacy of manipulation 
is requisite ; and peculiarly so while exposing the vessel and passing the 
aneurismal needle. The chief dangers to be avoided in the deligation 
of an artery are, its undue exposure and separation from its connexions 
laterally and posteriorly, — treatment which would insure sloughing of 
that portion, and consequent secondary hemorrhage ; the wounding of 
veins, which accident would cause troublesome hemorrhage, and possibly 



DELIGATION OF ARTERIES. 637 

induce phlebitis, or in some veins of the neck and axilla, might cause 
instant death by giving entrance to air ; and, lastly, the including of a 
vein or nerve in the ligature, a circumstance which, happening to one 
nerve at least, the pneumogastric, would, if not discovered and cor- 
rected, speedily prove fatal ; as indeed has been known to occur. The 
ligature becomes loose by absorption, ulceration, or sloughing of the 
portion of arterial tunic within its noose, in a period varying from ten 
to twenty, or even thirty days. At the expiry of the third week, it may 
be gently touched, when, if loose, it will come away immediately ; but 
if the slightest resistance is felt, no force must be employed. In a few 
days it may again be tried, as, when left to itself, it frequently remains 
a considerable time in the wound after its complete detachment, delaying 
thereby the complete healing of the wound, and protracting the period 
of anxiety as to its safe separation naturally experienced both by surgeon 
and patient. 

DELIGATION OF THE COMMON CAROTID ARTERY. 

[This operation was first performed for aneurism by Sir Astley 
Cooper, in 1805.— Ed.] 

The common carotid may be tied above or below where the artery is 
crossed in front by the omohyoid muscle. 

In the first-mentioned situation, deligation of the common carotid, is 
termed the superior operation. It may be required for wound or 
aneurism of any of its branches, and may be performed in the following 
manner : — 

The patient being placed on his back, with the chest a little raised, a 
small cushion under the nape of the neck, so as to make it prominent in 
front, and the head thrown well back, with the face thrown to the oppo- 
site side from that on which the artery is to be tied, an incision is 
made from the part nearly opposite the angle of the jaw, to a little 
below the level of the cricoid cartilage, along the inner border of the 
sterno-mastoid muscle, which forms the guide to the vessel, and of 
which the course corresponds with a line drawn from the sternal ex- 
tremity of the clavicle in the direction of the mastoid process. The 
skin, subcutaneous, cellular, and adipose tissue, the platysma myo- 
ides, and the layer of cellular tissue beneath being successively di- 
vided, the head is then turned a little, so as to relax the parts about 
the wound and permit its edges to be drawn apart, any superficial 
veins being at the same time drawn aside. The deep fascia is now 
to be pinched up with a forceps, and cut in the cautious manner 
formerly described ; which being done, the sheath of the vessels will 
be found in the angle formed by the sterno-mastoid and omohyoid 
muscles. 

The descendens noni nerve, or some of its branches, will be seen in 
this stage, and must be carefully guarded from injury. The sheath 
appears of a dark colour towards its outer part, where it covers the vein, 
but of a lighter hue on its inner aspect, where it conceals the artery ; 
and is occasionally pierced by a vein from the thyroid body which runs 
across the carotid artery about the middle of the neck to enter the inter- 
nal jugular. This vein, when present, must not be cut, as it would yield 



638 



DELIGAT10N OF ARTERIES. 



much blood, and obscure the farther progress of the dissection in its 
most delicate stage. The sheath is opened to the extent of half an inch 
towards its tracheal side — that is over the artery rather than the vein, 
so as to confine the latter, which being very large, slightly overlaps the 

Fig. 244. 




former, especially in expiration, when it becomes very turgid. The 
proper mode of opening it is, as before explained, by pinching it up 
with a forceps, and cutting horizontally as in opening a hernial sac. If 
this vein bulge so much as inconveniently to cover the artery, a finger 
may be pressed over it in the upper part of the incision^ with the effect 
of diminishing the quantity of descending blood. The artery is the 
most internal of the three objects within the sheath, the vein being the 
most external ; while the pneumogastric nerve lies between the two ves- 
sels, and rather behind them. The artery being now sufficiently exposed 
in front, a slightly curved aneurismal needle armed with ligature is 
passed round it, from without inwards, so as to preserve the vein and 
nerve from injury, and the latter from being included by the thread. 
The operation is then finished according to the general rules previously 
laid down. 

When we wish to secure the primitive carotid, whether on account of 
the existence either of aneurism or wound of its branches, the superior 
operation is to be preferred, on account of the comparatively superficial 
situation of the vessel ; but when the aneurism occupies the trunk, we 
are obliged to place the ligature below, where the artery is crossed by 
the omohyoid muscle : in which case the operation is called the inferior, 
and is more easily performed on the right side than on the left ; but 
it is likewise more dangerous, because the proximity of the subclavian 

Fig. 244. From Liston. 



DELIGATION OP ARTERIES. 639 

will increase the difficulty of the formation of the internal coagulum in 
the origin of the carotid. The first incision should be about three inches 
in length, commencing immediately above where the artery is crossed 
by the omohyoid, and extending along the course of the vessel. After 
cutting through the skin, subcutaneous, cellular and adipose tissue, the 
platysma myoides, and the cellular tissue beneath, the sterno-mastoid 
is to be drawn backwards, and the sterno-hyoid and sterno-thyroid 
forwards, when the deep cervical fascia is brought into view ; after 
which the remaining steps are to be proceeded with as in the superior 
operation. 

DELIGATION OF THE SUBCLAVIAN ARTERY. 

[This artery was first tied by Mr. Ramsden, 1809, although Sir 
Astley Cooper attempted it in the early part of the same year. The first 
successful case occurred to Dr. Post, of New York, in 1817. — Ed.] 

The operation of tying the subclavian artery on the acromial side 
of the anterior scalenus muscle may be required in aneurism of the 
axillary artery, and may be performed in the following manner: — 
The patient being placed in the recumbent posture, with the shoulder 
depressed as much as possible, the head slightly inclined to the oppo- 
site side, and the integument in front of the chest drawn down by 
an assistant, the surgeon divides the skin upon the clavicle, from the 
acromial border of the sterno-mastoid muscle to the clavicular attachment 
of the trapezius. On the hands of the assistant being removed, the 
wound rises above the clavicle, becoming parallel to it in the under 

Fig. 245. 




region of the neck. A short incision along the posterior border of 
the sterno-mastoid muscle is made to end in the first line of the 
wound. The platysma myoides and fascia should then be cautiously 
divided, care being taken after division of that muscle not to injure 
the external jugular vein, which passes down under the muscle near 

Fig. 245. From Liston. 



640 DELIGATION OF ARTERIES. 

the middle of the horizontal incision. On dividing the cellular tissue 
along its inner border, the vein can, in general, be easily kept out 
of danger, by being gently drawn to the acromial aspect of the wound 
by means of a copper spatula. The various tissues having been di- 
vided, from the acromial margin of the sterno-mastoid to the inner 
border of the omohyoid muscle, the cellular tissue covering the small 
triangle formed by the two scaleni muscles and a portion of the first 
rib should next be divided, and the suprascapular artery held towards 
the scapula by another copper spatula. The acromial border of the 
anterior scalenus muscle should be exposed ; and on tracing it down to 
the first rib, the artery will be found in the angle formed by that margin 
of the muscle and the first rib, lying internal and inferior to the lower 
fasciculus of the brachial plexus. The ligature is then passed under- 
neath the artery by an aneurismal needle ; and, in doing so, the prefera- 
ble proceeding is, to direct the convexity of the instrument towards the 
clavicle, to apply its point close to the artery, and to carry it round in 
such a way as not to disturb the artery, except above, to a greater ex- 
tent than is produced by the track of the needle. When the ligature 
cannot be drawn by the fingers pressed down on the vessel, it may be 
run close by means of a notched probe. The principal risks to be 
guarded against in performing this operation are, — wounding the ex- 
ternal jugular vein, the suprascapular artery, and the subclavian vein ; — 
detaching the artery from its surrounding connexions to an undue ex- 
tent ; or, mistaking a fasciculus belonging to the brachial plexus for the 
artery. In connexion with this operation, it should be borne in mind, 
that a large communicating branch sometimes runs superficially to the 
clavicle between the cephalic and external jugular veins, which, when 
present, would probably be divided in the first incision. The sterno- 
mastoid and trapezius muscles are occasionally attached to a much 
greater length of the clavicle than usual, and in such a case their fibres 
to some extent must necessarily be divided, in order to obtain an ex- 
ternal wound affording sufficient freedom. The omohyoideus also has 
been known to contract an additional attachment to the clavicle near its 
scapular extremity. 

DELIGATION OF THE AXILLARY ARTERY. 

The axillary artery may be tied with great facility in its lower third, 
below the origin of its subscapular and circumflex branches, when the 
arm is abducted and rotated outwards very much, in which position the 
anterior fold of the axilla is removed from the vessel. The forearm 
should be kept supinated and slightly bent, so as to prevent painful ten- 
sion of the nerves. The guide to the artery here is the inner margin of 
the coraco-brachialus muscle ; and the pulsations can also be easily felt. 
An incision, about three inches long, is made in the direction indicated, 
cutting through the tense integument and the subcutaneous cellular tis- 
sue. Then the deep fascia being completely divided, the median nerve 
is exposed, lying in front of the artery. The arm may now be lowered 
somewhat, so as to relax the parts, and permit the median nerve to be 
drawn aside, and facilitate the easy passage of the aneurismal needle 
round the artery. This is effected from within outwards, in order to 
secure from injury the axillary vein, which lies internal and anterior to 



DELIGATION OF ARTERIES. 



641 



the artery, as well as the internal cutaneous and ulnar nerves, which lie 
on its inner aspect. The radial nerve is behind, but in little danger. 



Fig. 246. 




^fl- 



it must be remembered that the humeral veins sometimes run up for 
some distance in the axilla, before they unite to form the axillary ; and 
also, that the artery sometimes divides in the same space into two 
branches, which afterwards become the radial and ulnar. 

DELIGATION OF THE HUMERAL ARTERY. 

The humeral or brachial artery may be tied in any part of its course. 
The arm is to be abducted, and sufficiently rotated outwards, while the 
forearm is supinated, and, after the first incision, slightly flexed. The 
guide to the vessel, in the upper portion of its course, is the inner margin 
of the coraco-brachialis ; in the middle and lower parts, that of the biceps ; 
and in the lower portion of the arm, that of the tendon of the last 
muscle. In the former situations, the external incision should be about 
three inches in length ; in the latter, it may be somewhat shorter. The 
integument and superficial fascia 

are first cut through ; after Fig. 247. 

which the deep aponeurosis is 
cautiously divided, the basilic 
vein being drawn inwards and 
out of danger. The internal 
cutaneous nerve in the upper 
part of its course lies near the 
line of incision, but in the lower, 
becomes internal to the vessel, 
and the deep brachial veins em- 
brace the artery laterally, and 
frequently communicate by cross 
branches which pass in front or 
behind. These communicating 
twigs are to be avoided. The 
occasional high division of the 
brachial artery must be remembered. When this occurs, the two vessels 

[Figs. 246 and 247. From Skey.— Ed.] 
41 




642 



DELIGATION OF ARTERIES. 



run side by side, and are evidently much smaller than the single trunk 
usually present. Before finally tightening the ligature, it is necessary to 
observe, by the effect of compression, which vessel is chiefly implicated in 
the disease. Probably both will require deligation. It is worthy of 
remark, that of the two vessels, the one which afterwards becomes the 
ulnar, furnishes nearly all the regular branches normally distributed by 
the humeral artery. 

DELIGATION OF THE RADIAL AND ULNAR ARTERIES. 

The radial artery may be tied on the anterior aspect of the forearm, 
by making an incision from two to three inches in length, carried along 
the inner margin of the supinator radii longus in the upper portion; but 
in the lower part, along the outer edge of the tendon of the flexor carpi 
radialis, which can here be more distinctly traced than that of the former 



Fig. 248. 




muscle. The course of the artery in this region corresponds with a 
line drawn from midway between the condyles of the humerus, obliquely 
downwards and outwards, to a point a little internal to the styloid pro- 
cess of the radius. * After cutting through the skin, and the superficial 
and deep fascia, the artery is found accompanied by vense comites. In 
the middle third of the arm, a nerve — the radial branch of the musculo- 
spinal, or, according to a different nomenclature, the dorsal cutaneous 
branch of the radial nerve, — lies at a little distance on the radial side 
of the vessel ; but it is scarcely in the way of the needle ; and else- 
where, it is still farther removed. The radial artery may also be tied 
on the dorsum of the hand, before it dips into the space between the 
first and second metacarpal bones on its way to the palm. The incision 
is made along the extensor tendon of the extreme phalanx of the thumb, 

either on its radial or ulnar aspect, 
Fig- 249. according as the thumb is approxi- 

mated to, or abducted from the 
index finger. The skin, cellular 
tissue, and a delicate dorsal fascia 
are divided, along with some mi- 
nute nervous and venous twigs. 
The ulnar artery may be tied in 
the middle and lower third of the 
forearm, or at the wrist. In the 
lower third, it is easily exposed by 
an incision of two or three inches in length, carried along the radial 
border of the tendon of the flexor carpi ulnaris, through the skin and 

[Figs. 248 and 249. From Skey.— Ed.] 




DELIGATION OP ARTERIES. 643 

the superficial and the deep aponeurosis. The artery is found lying 
close on the radial side of the tendon, and rather deeper. The ulnar 
nerve is here applied rather closely on the ulnar aspect of the vessel, 
and is accordingly to be avoided by passing the needle between them 
from the ulnar towards the radial side. The vense comites are at the 
same time to be preserved from injury. In the middle third, the artery 
is rather deeply situated, but may be reached by a free incision, guided 
by tracing up the tendon of the flexor carpi ulnaris, on the radial side 
of which muscle the division of the integument, fascia, and deep apo- 
neurosis is to be effected. The artery is exposed between the muscle 
already named and the superficial flexor of the fingers. Here also the 
ulnar nerve is found on the ulnar side of the vessel. At the wrist, this 
artery may be tied, after dividing for about two inches the integument 
and fascia along the radial side of the pisiform bone and the tendon of 
the ulnar flexor, in which situation the vessel is found, having the nerve 
still related to its inner side. 

THE EXTERNAL ILIAC ARTERY. 

[To Abernethy belongs the credit of first tying this artery. The 
case terminated successfully. — Ed.] 

The external iliac artery is secured in the following manner : — The 
patient is placed with his shoulders well raised, and the thighs slightly 
flexed, so as moderately to relax the abdominal parietes. An incision, 
from four to five inches long, but varying in length according to the 
corpulence of the individual, is commenced a little above the centre of 
Poupart's ligament, and carried upwards with a slight inclination out- 
wards, so as nearly to correspond with the course of the fibres of the 
tendon of the external oblique muscle, named by many the anterior 
layer of the abdominal aponeurosis. In this first incision the integu- 
ment and superficial fascia are divided. The aponeurotic fibres just 
mentioned are separated along the line of wound with as little cross-cut- 
ting as possible. The fibres of the internal oblique and transversalis 
muscles are next divided very cautiously, employing the forceps when 
necessary. The part of the transversalis fascia, which at the internal 
aperture of the inguinal canal is thinned, and sends off a tubular pro- 
longation downwards over the spermatic cord, is pinched up at this 
spot, and opened immediately externally to the cord with great caution, 
so as not to wound the peritoneum which lies directly behind. The 
finger is now inserted into the aperture thus made in the transversalis 
fascia, and gently insinuated between it and the peritoneum, with which 
guard against wounding that membrane, the fascia, is divided, like the 
other layers, upwards and outwards to the same extent. During the 
progress of the operation the margins of the wound are to be kept well 
apart by means of bent copper spatula. The peritoneum is then 
detached at the lower and outer aspect of the wound, and as far as 
requisite from the iliac fascia, by gently insinuating the fingers and 
opening up its delicate cellular connexions, which at this part are 
remarkably loose. The inner margin of the wound, and the peritoneal 
sac, are now drawn inwards so as to expose the vessels. The artery is 
separated from the vein, which lies on its inner and posterior aspect, by 
a scratch with the point of the scalpel, and that sufficiently to permit 



644 



DELIGATION OF ARTERIES. 



the introduction of the point of the aneurismal needle between them, at 
some little distance above the origin of the deep epigastric artery, car- 
rying the instrument from within outwards. When, owing to the thick- 
ness of the abdominal parietes and the consequent depth of the artery, 
it is impossible to encircle it with the common needle or to tighten the 
knot by pressing the fingers down on each entwinement, then Weiss's 
aneurismal needle and the notched probe maybe employed to accomplish 
these ends. After operation, the parts are replaced, the wound being 
maintained in apposition by a few sutures, while the limbs are still farther 
raised, so as to relax the abdominal parietes and the deligated vessel. 

THE COMMON ILIAC ARTERY. 

[No one had attempted the tying of the common iliac artery until 

1827, when it was successfully per- 
Fig. 250. formed by Dr. Mott, of New York. 

—Ed.] 

The common iliac artery is 
reached by proceeding in the same 
w T ay as above described for the 
external iliac. This vessel is traced 
up until the primitive trunk is dis- 
covered. The external incision 
must, however, be longer, varying 
from five to six inches ; and the 
peritoneum requires detachment to 
a greater extent upwards and in- 
wards. The ureter crosses in front 
of this vessel, near its bifurcation, 
but is usually raised up along with 
the peritoneum ; if not, it must be 
avoided. It should also be remem- 
bered, that while the vein of each 
side lies posterior to its corres- 
ponding artery, the vein of the 
right side inclines also a little to the outer aspect, and that of the left 
to the inner aspect of the vessel which may require deligation. 

THE INTERNAL ILIAC ARTERY. 

[This vessel was secured in a ligature by Dr. Wm. Stevens of St. 
Croix, West Indies. The operation was performed for gluteal aneurism 
on a negress. — Ed.] 

The internal iliac artery may be tied by a similar proceeding to that 
for the common iliac. It will be found by tracing up the external iliac 
to the point at which the primitive vessel bifurcates on the sacro-iliac 
junction. The ureter crosses in front and the vein lies behind. The 
latter, however, on the right side is also a little external, and on the left 
it is somewhat internal to the artery. 

DELIGATION OF THE COMMON FEMORAL ARTERY. 

Deligation of the common femoral artery is a very easy, though not 




Fig. 250. From Liston. 



DELIGATION OF ARTERIES. 



645 



likely to be a very successful operation, on account of the proximity of 
the ligature to the origins of the epigastric and circumflex iliac vessels 
above, and that of the profunda femoris below. The artery emerges 
from beneath Poupart's ligament, midway between the anterior superior 
spine of the ilium and the spine of the pubes. Its pulsations, moreover, 
in the natural state of parts, are easily felt. The skin may be divided 
by an incision of two or three inches in length downwards from a little 
below Poupart's ligament. The saphena major vein being then drawn 
aside, if in the way, the loose cellular tissue and any glands present are 
carefully cut through. The fascia and proper sheath are then opened, 
and the point of the scalpel employed, if necessary, to scratch the 
cellular tissue between the vessels, and afford a commencement to the 
entrance of the aneurismal needle, which is carefully passed from within 
outwards, so as not to injure the vein, which lies internal to the artery. 

The fittest point at which to secure the femoral artery after it has given 
off the profunda, is, immediately before it runs beneath the sartorius in 
the angle formed by that muscle and the adductor longus. The vessel 
may usually be traced by its pulsation downwards and inwards from the 
centre of Poupart's ligament. The 

incision should pass over the angle Fi S- 251 - 

formed by the sartorius and the 
adductor longus, should be directed 
downwards and a little inwards, be 
about three inches in length, and cut 
through the integument and super- 
ficial fascia. The fascia lata is 
pinched up by the dissecting for- 
ceps, and carefully divided, avoiding 
any twigs of the anterior crural 
nerve, which are here found in front 
of the artery as the incision deepens. 
Lastly, the sheath found in the 
angle mentioned above is opened 
with the usual caution, for about 
half an inch. 

The femoral artery and vein are 
much more intimately covered and 

connected together by cellular sub- | \fjjf | 

stance than any other vessel. Ac- 
cordingly, the former must be 
cleared of this loose tissue for a 
minute space in front, till its ex- 
ternal tissue is seen distinct and 
white, the forceps and point of the ■ 

scalpel being employed in this deli- 
cate part of the operation. Then the aneurismal needle may be safely 
and easily passed round the vessel, from within outwards, the vein lying 
internal and posterior, and the nerve on the outer or iliac side. It 
must be remembered, that the femoral artery is, like the humeral, some- 




Fig. 251. From Liston. 



646 



DELIGATION OF ARTERIES. 



times found double, and that deligation of one of the vessels would 
probably fail in producing the desired result. 

THE POPLITEAL ARTERY. 

The popliteal artery is now very seldom made the subject of opera- 
tion, though the disease in it frequently necessitates deligation of the 
femoral. It may be secured by making an incision, about four inches 
in length, down the centre of the popiliteal region, commencing in the 
upper part of this space, and cutting through the skin and superficial 
fascia. Subsequently the aponeurosis is divided, and the surgeon cau- 
tiously deepens the dissection along the outer margin of the semitendi- 
nosus and semimembranosus muscles. The vessels are at last reached, 
lying in a quantity of cellular tissue ; and when this is sufficiently cleared 
aside, the vein is discovered lying superficially to the artery. The 
former must be gently drawn aside, and the intimate cellular connexion 
between it and the artery being loosened at one point by a delicate touch 
with the point of the scapel, the needle may be gently insinuated and 
passed around the latter from within outwards, a little higher up than 
the plane of the knee-joint. The internal popliteal nerve, lying super- 
ficially to the artery, and towards its outer side in this part of the space, 
must, if exposed, be drawn out of danger. The popliteal vein has also a 
slightly external, as well as a posterior relation to the artery. 

THE ANTERIOR TIBIAL ARTERY. 

The anterior tibial artery is easily reached in the lower third of the 

leg, by an incision, two or three 
inches in length along the outer side 
of the tendon of the tibialis anticus, 
cutting through skin, superficial 
fascia, and the deep aponeurosis of 
the leg. The artery here lies on the 
outside of that tendon, between it and 
that of the extensor proprius pol- 
licis, with the corresponding nerve 
in front, and a vena comites on either 
side. If the incision be made too 
far down, the tendons of the extensor 
proprius pollicis would be found cross- 
ing over in front of the artery, in 
immediate proximity to the ankle- 
joint. 

On the middle third of the leg, 
this vessel lies deeper and requires 
an incision of proportionate length, 
which is guided either by selecting 
the middle line between the crest of 
the tibia and the borders of the fibula, 
or by tracing up the tendon of the tibialis anticus, along the outer margin 



Fig. 252. 




Fig. 252. From Liston. 



DELIGATION OF ARTERIES. 



647 



of which muscle the division is to be effected. After separating this 
muscle from the extensor proprius pollicis, the artery is found between 
them, with its venae comites placed as usual, and the anterior tibial nerve 
lying generally in front. 

In the upper third of the leg, this artery lies very deep, being covered 
by the apposition of the tibialis anticus on its inner side, with the ex- 
tensor longus digitorum on its outer aspect. The incision must be at least 
four inches in length ; and is to be carried down in the central line, be- 
tween the crest of the tibia and margin of the fibula. The skin and super- 
ficial fascia being divided are drawn apart, and the muscular interspace 
is sought for by moving the foot, and so making the muscles start up ; 
or it can generally be observed by a yellow line, marking the spot 
where the aponeurosis is thickened at the attachment of the intermuscular 
septum. Moreover, the cutaneous incision made in the course indicated 
corresponds almost exactly with this interspace. The deep fascia is then 
divided along this line, and the separation of the muscles effected by the 
handle of the scalpel, or if necessary, by its edge also. The artery is 
at last found, with a vena comites on each side ; and the nerve in this 
situation lying on its outer aspect. The aneurism needle may then, with 
the usual precautions, be passed from the fibular to the tibial side. 

DELIGATION OF THE POSTERIOR TIBIAL ARTERY. 

The posterior tibial artery may be tied behind the mner ankle, when 
the foot is flexed and turned inwards, by making an incision midway 
between the internal malleolus and 
the tendo Achillis, curving gently Fig- 253. 

forward at its lower part, and extend- 
ing to two or three inches in length. 
The skin and superficial fascia are 
cut through, and subsequently the 
strong aponeurosis is divided, when 
the artery will be found, accompanied 
on either side by a vein, and by the 
posterior tibial nerve on its outer as- 
pect towards the tendo Achillis. The 
tendon of the flexor proprius pollicis 
is also placed on the fibular aspect of 
the artery, and those of the flexor 
longus digitorum and tibialis posticus 
run on its tibial side, or near the 
inner ankle. The foot should be slight- 
ly extended, while the needle is being 
passed from the tibial to the fibular 
side, so as to relax the tissues and 
facilitate its transit. 

In the middle of the leg, deligation 
may be effected by making a very free 
incision between the tibia and the margin of the gastrocnemius, which 




Fig. 253. From Liston. 



648 DELIGATION OF ARTERIES. 

muscle is drawn aside. The soleus is next detached from its tibial origin, 
and is also pulled aside. Lastly, the deep layer of the tibial aponeuro- 
sis is divided, and the vessel reached, accompanied by its venae comites 
and the nerve, which, about the middle of the artery, lies superficially 
to the vessels. If deligation be required on account of a wound of the 
artery, the vessel must be tied above and below the seat of the injury. 

DELIGATION OF THE DORSAL ARTERY. 

The continuation of the anterior tibial artery on the dorsum of the 
foot, known as the dorsal artery, may be tied about the middle of its 
course, by making an incision through the skin, fascia, and aponeurosis, 
along the outer or fibular side of the tendon of the extensor proprius 
pollicis, where the artery will be found, with the innermost tendon of 
the extensor longus digitorum on its outside. A vein runs on either 
aspect, as usual, and the continuation of the anterior tibial nerve runs 
externally and superficially to the artery. 



649 



CHAPTER XX. 
AFFECTIONS OF THE EECTUM. 

RECTITIS, OR INFLAMMATION OF THE RECTUM. 

Causes. — Rectitis may be produced by extension of inflammation from 
neighbouring parts, — by external injury, — by hemorrhoids in an in- 
flamed state, — by alterations of temperature, — by foreign or irritating 
substances in the bowel, — or by operations performed on the rectum or 
near it. Sometimes, though very rarely, it occurs as an idiopathic 
disease. 

Symptoms. — In acute rectitis, in addition to the usual symptoms of 
very smart irritative fever the patient experiences a sense of fulness and 
weight in the rectum, a bearing down, a distressing burning heat, and 
excruciating pain, aggravated to a most agonizing extent by tenesmus 
and contraction of the sphincter muscle. 

In many cases there is, after a short time, a scalding discharge of a 
muco-purulent matter, and in most instances the urinary organs sympa- 
thize, so that, in addition to the symptoms affecting the rectum, the 
patient is distressed with strangury, or painful micturition, or even with 
retention. 

Treatment. — The treatment consists in removing, if possible, the cause 
of the disease, in confining the patient to the recumbent position, in 
enjoining the strict observance of the antiphlogistic regimen, in institu- 
ting local depletion by the application of leeches around the anus, in 
obviating constipation by the use of the mildest enemata, in the diligent 
and efficient employment of warm and emollient applications, and in 
allaying the tenesmus, contraction of the sphincter ani, pain of the rec- 
tum, and the distressing symptoms affecting the urinary organs, by the 
use of opiates, which may be applied to the rectum in the form of enema, 
or by suppository, or diffused through ointment : in some instances it is 
necessary to give them by the mouth. 

Ulceration of the rectum, deposit of lymph between the coats, — lay- 
ing the foundation of stricture, — perforation of the rectum by ulceration, 
extension of inflammation to the surrounding cellular tissue — producing 
abscess in the first instance and afterwards fistula — are some of the con- 
sequences of this painful affection when not speedily subdued; and in 
order to their prevention, the treatment should be as energetic as the 
circumstances of the case seem to justify. 

FISTULA IN ANO. 

When a fistula has an external and internal opening, it is said to be 
complete ; when an external opening only, it is called a blind external, 



650 



AFFECTIONS OF THE RECTUM. 



and when it has only an internal opening, a blind internal fistula ; in 
the two latter cases the fistula is said to be incomplete. 

This affection is much more common in men than in women, and the 
period of life at which it most frequently occurs is between twenty and 
fifty years of age. The situation of the external Opening is usually at 
the side of the anus, very rarely either before or behind ; and with regard 
to the situation of the internal opening, M. Ribes found, on examining 
seventy-five bodies in which fistula existed, that in all cases in which 
there was an internal opening, it was not high up, but immediately 
within the sphincter muscle. This observation accords with the expe- 
rience of Sabatier, Larrey, and many others. 

Before performing an operation for the cure of fistula, it is of the 
greatest importance to ascertain that the disease is entirely local, in 
which case the desired result will be obtained ; whereas, if the disease 
be connected with pelvic abscess, or with disease of the sacrum, or with 
organic disease of the lungs, liver, or any other important internal 
organ, the surgeon will bring discredit on himself by recommending an 
operation. 

Sir Astley Cooper remarks, " The surgeon often brings discredit upon 
himself by operating in these cases in the last stage of phthisis ; and 
when, it is impossible that the disease can be cured ; therefore, that 
death which is the result of pulmonary disease is falsely attributed to 
the fistula in ano." 

Sir Benjamin Brodie observes, " In those cases in which a fistula in 
ano occurs in connexion with some organic disease of the lungs or liver 
I advise you never to undertake the cure of the fistula. No good can 
arise from an operation under these circumstances ; but if you perform 

Fig. 254. 




it, one of two things will happen — either the sinus, although laid open, 
will never heal, or otherwise, it will heal as usual, and the visceral disease 
will make more rapid progress afterwards, and the patient will die 
sooner than he would have done if he had not fallen into your hands." 

Fig. 254. From Liston. 






AFFECTIONS OF THE RECTUM. 651 

The frequent motion caused by the contraction of the sphincter ani 
being the principal obstacle to the healing of fistula in this situation, the 
immediate object aimed at by operation is the division of that muscle. 
In complete fistula this may be readily accomplished by introducing the 
forefinger of one hand into the rectum, introducing a curved blunt- 
pointed bistoury through the fistula into the rectum, resting the point of 
the forefinger against the back of the point of the instrument in the 
rectum, bringing it down through the anus, and dividing the sphincter. 
The instrument should always be made to pass into the bow T el through 
the internal opening, and the parts below it divided ; but any division 
of the bowel above that opening is perfectly unnecessary. When no 
internal opening exists, the bistoury should be pressed into the bowel at 
the usual situation of that opening, where the coats of the rectum will be 
found to be attenuated ; and when there is no external opening, the in- 
tegument covering the under part of the fistula, which will be found thin 
and unsupported, and surrounded by a part which feels thick and hard- 
ened under the adjacent portions of the skin, should be divided so as 
to make an external opening, and then the same operation as for com- 
plete fistula is performed. A little lint dipped in oil should be intro- 
duced immediately after the operation, and the parts afterwards dressed 
for some days with lint soaked in some lotion. 

HEMORRHOIDS. 

Hemorrhoids, or piles, are swellings at the verge of the anus, pre- 
senting varieties both as to situation and nature. 

The Causes of hemorrhoids have been arranged into predisposing 
and exciting. To the former class may be referred habitual constipa- 
tion, sedentary occupations, pregnancy, abdominal tumours, some affec- 
tions of the liver, and any condition capable of retarding the circulation 
in the portal system, or of preventing the free return of the blood from 
the veins of the rectum. To the latter class belong straining at stool — 
irritation of the rectum induced by hardened faeces, by purging, or by 
tenesmus — sympathy of the rectum with affections of the urinary blad- 
der — and long maintenance of the erect posture, by which the flow of 
blood is rendered difficult in the portal system, unprovided as it is with 
valves. Such are some of the predisposing and exciting causes. The 
rationale of their operation will be readily perceived, when the nature 
of hemorrhoidal swellings is explained. 

Varieties as to Situation and Nature. — Hemorrhoids are called ex- 
ternal or internal, according as they are without or within the sphincter 
ani. 

External Hemorrhoids. — With regard to anatomical characters, ex- 
ternal hemorrhoids may be said to consist of a varicose condition of 
some of the hemorrhoidal veins. The veins may be merely dilated and 
the cellular tissue around them in a natural state ; or they may be di- 
lated and inflamed, .presenting the varieties with regard to condition of 
coats and contents mentioned in the description of the parts in phle- 
bitis, with the surrounding cellular tissue more or less inflamed, or con- 
taining products of inflammation, or, if the hemorrhoids have been of 
long standing, more or less hypertrophied. While external hemor- 



652 AFFECTIONS OF T H E RECTUM. 

rhoids continue in a quiescent and indolent condition, the contents of 
the dilated veins remain in a fluid state, and comparatively little dis- 
comfort is experienced ; but when they become inflamed, the pain and 
bearing down are great. The coats of the distended vein may at some 
parts give way, and a discharge of blood take place, constituting what 
has been termed open or bleeding piles ; or the contents may become 
consolidated, as in the forms of phlebitis in other parts of the body ; or 
abscess may be the result. 

Internal Hemorrhoids. — Of these there are three varieties. First, 
those which consist of erectile tissue which seems to be developed prin- 
cipally in the submucous cellular tissue. — Second, those which are of 
the same nature as external hemorrhoids, consisting of portions of 
varicose veins covered by mucous membrane, and presenting the same 
varieties as to quiescence or irritability, and as to condition of coats 
and contents, with this difference, that they cause much more uneasiness 
and are attended with more sympathetic irritation, — the symptoms 
affecting the urinary organs being often very distressing. — The third 
variety, which rarely occurs, consists of those which are of the nature 
of simple sarcoma. 

Treatment. — The treatment may be either palliative or radical. 

The palliative treatment of external hemorrhoids when in a state of 
inflammation consists in the removal of the cause, if possible and proper, 
in local depletion by means of leeches, and in some cases by the free 
division of the hemorrhoid, in regulating the bowels by gentle, non-ir- 
ritating medicines, in the occasional use of the warm hip-bath, and in the 
strict observance of the horizontal position. In the chronic stage, the 
local part of the palliative treatment consists in the use of cold applica- 
tions and astringents. 

The palliative treatment of internal hemorrhoids when in a state of 
inflammation, may be said to consist in the employment of the remedies 
already mentioned as proper in the treatment of rectitis. 

The radical treatment proper to be instituted, having for its object 
the removal of the hemorrhoids, differs greatly according as the hemor- 
rhoids are external or internal. In the former case, the proper and 
easy proceeding is, to remove them by the knife or the scissors ; whereas 
internal hemorrhoids, with the exception of the comparatively rare 
variety in which they are of the nature of simple sarcoma, can be safely 
removed only by ligature. The great danger of hemorrhage, and the 
difficulty of averting it, have led almost all surgeons of much experience 
to this conclusion. The mode of proceeding is as follows : — The bowels 
having been well moved, the hemorrhoids are made to protrude by 
straining, and the nates being separated from each other by an assistant, 
the tumours are seized with a volsellum, and the surgeon ties them firmly 
by means of a silk thread round their roots, if they be small and pen- 
dulous ; if otherwise, they may be transfixed at the base by a needle, 
and one-half included in each of the threads. The ends of the threads 
should then be cut off, the strangulated portions of bowel and that pro- 
truded carefully returned, and the patient confined to the horizontal 
position until the ligatures come away. An opiate should be given to 
allay pain and prevent motion of the bowels, and the state of the 






AFFECTIONS OF THE RECTUM. 653 

urinary organs attended to. If the patient complain of much discom- 
fort, warm fomentations and poultices may be applied. 

To the benefit and satisfactory results of this method of treatment, I 
am sure that all surgeons who have had sufficient experience of it will 
be able to give the most favourable testimony. In cases in which the 
principal characteristic is a diseased condition of the mucous membrane 
placed over varices or altered cellular tissue — a form in which there is 
great irritation and often considerable loss of blood — Mr. Houston has 
used with advantage the nitric acid. The bowel having been made to 
protrude, and the part having been wiped with lint, the acid is applied 
to a small part ; this is followed by the application of some oil to the 
same part, and the return of the protruded portions of the bowel ; after 
which an opiate is given. The surface is said in general to heal very 
rapidly after the separation of the superficial slough. I cannot say any- 
thing of this mode of treatment from personal observation, but in the 
class of cases above referred to, the result has been found by Mr. Hous- 
ton and some others to be very satisfactory. 

RHAGADES. 

Fissures, excoriations, and cracks are very frequently met with at the 
verge of the anus, especially in persons much troubled with disorder of 
the digestive organs. They cause much pain, which is greatly increased 
while the bowels are being moved, and for a considerable time afterwards. 
They also give rise to spasm of the sphincter, which aggravates the pain ; 
and if of long standing, they lead to permanent stricture. It is surprising 
how much suffering often results from a very small fissure in this situation. 

By the careful regulation of the bowels, attention to diet, and local 
treatment consisting of application to the part of nitrate of silver, or 
nitric acid, this troublesome complaint is sometimes removed ; but more 
frequently an operation is necessary, the object of which is to convert 
the fissure into a simple wound. This is effected by making a slight in- 
cision passing through the fissure, and dividing, according to the extent 
of the fissure, either the mucous membrane and submucous cellular tissue 
alone, or these parts together with the sphincter, so as to set the parts 
at rest ; after which they heal up very kindly under the treatment for a 
simple wound, and the disease is removed. 

I have performed this operation in many cases, and never found it 
necessary to do more than make a longitudinal incision through the 
mucous membrane and the submucous cellular tissue ; but many surgeons 
state that, in cases occurring in their experience, it has been requisite 
to divide the sphincter also. 

PROLAPSUS ANI. 

Prolapsus ani may be either partial or complete, and it may occur in 
children, in adults, or persons of an advanced age. 

PARTIAL PROLAPSUS. 

Partial prolapsus, which consists in protrusion of a portion of the 
mucous membrane, is chiefly met with in adults, is almost invariably 
induced by internal hemorrhoids, and is immediately caused by exertion. 



654 | AFFECTIONS OF THE RECTUM. 

The treatment of this variety, — called by some authors partial pro- 
lapsus, by others prolapsus from hemorrhoids, — may be clearly under- 
stood from what has been stated regarding the treatment of internal 
hemorrhoids. 

COMPLETE PROLAPSUS. 

Complete prolapsus presents the appearance of a swelling, for the 
most part of a globular form, and consists of an invagination of a por- 
tion of the bowel, constituting a condition similar to that which within 
the abdomen is called intussusception. 

Complete prolapsus may be said to be almost entirely confined to 
infancy and childhood, and old age. In early life it is almost invariably 
induced by straining at stool, tenesmus, or violent crying; and any 
condition by which these causes are called into existence may lead to 
prolapsus, such as an acrid condition of the contents of the bowels, irri- 
tation of the mucous membrane, the presence of worms, pain in the 
bowels, calculus in the bladder, or the irritation of teething. This form 
of prolapsus has been called prolapsus from irritation. The treatment 
consists in returning the protruded part, and in using the proper means 
to prevent a recurrence of the protrusion. 

There are various proceedings by which the protruded parts may be 
returned. One is, having placed the patient in the horizontal position 
on his back or side, with the limbs drawn towards the abdomen, and, 
having oiled the parts, with one hand to compress the neck of the 
tumour, and with the other to press up the swelling within the sphincter, 
While these manipulations are being performed, the patient should 
endeavour to avoid straining, which, by compressing the abdomen, would 
render replacement more difficult. Another very satisfactory mode is, 
to lay the patient on his face, to spread a dry towel over the protruded 
parts, and then to send a finger gently up into the rectum. The bowel 
adheres to the towel, and is carried up along with it. The margin of 
the anus should be compressed, while first the finger and then the por- 
tion of towel are being withdrawn. 

The treatment for the prevention of reprotrusion must depend on the 
condition by which the exciting cause of the prolapse is brought into 
operation. 

In persons of an advanced age, prolapsus for the most part occurs 
from weakness and want of retaining power of the sphincter. This form 
has consequently been called prolapsus from weakness. Some of its 
causes are coughing, the erect posture, and walking to an extent to in- 
duce fatigue. After reduction, support by means of a compress and T 
bandage is necessary ; and the treatment for preventing a recurrence of 
the prolapse must be adapted to the particular circumstances of the case. 

From what has been stated, it is hoped that the causes, the condi- 
tions, and the treatment of the three forms of prolapsus, namely, from 
hemorrhoids, from irritation, and from weakness, will be clearly under- 
stood. 



AFFECTIONS OF THE RECTUM. 655 



STRICTURE OF THE RECTUM. 
I. SIMPLE ORGANIC STRICTURE. 

Seat. — This affection is commonly situated in the lower part of the 
rectum, about two or three inches from the verge of the anus, so 
that it can be readily reached with the finger, and its existence ascer- 
tained by examination. In some few instances it may have been found 
higher up, and some writers have expressed themselves with much con- 
fidence that this is its usual situation ; but dissection has shown, and all 
the greatest authorities are agreed, that it is almost invariably in the 
lower part of the rectum. 

Symptoms. — The principal symptoms are pain, difficulty and straining 
during defsecation, — the feces when solid being passed in small, flattened 
and narrow fragments, and, when fluid, ejected very forcibly. Of the 
early symptoms, difficulty of voiding the contents of the bowels is the 
most characteristic ; and at an advanced period of confirmed stricture, 
the very frequent and forcible discharge of thin fs&ces, with a copious 
secretion of mucus frequently tinged with blood— a consequence of 
irritation of the mucous membrane — is one of the most remarkable 
features. Such are the principal symptoms, but it is by examination 
that the existence of stricture is ascertained with certainty. Sympa- 
thetic irritation of the bladder, pains in the back and legs, disorder 
of the digestive organs, and general debility, occur as the disease 
advances ; and when not cured, it proves fatal for the most part by 
inflammation of the bowels, or by gradual sinking of the patient's 
strength. 

Condition of Parts. — There is a striking analogy between the condi- 
tion of parts in stricture of the urethra and in that of the rectum. In 
each case the stricture, although in some slight degree constituted by 
induration and thickening of the coats of the canal in which it is situated, 
is chiefly — it might almost be said, entirely — constituted by deposit into 
the submucous cellular tissue ; in the urethra, the part behind the stric- 
ture becomes dilated ; in the rectum, the part above ; in the urethra, 
the mucous membrane behind the stricture in many cases becomes 
ulcerated, giving rise to fistula in perineo ; in the rectum, the mucous 
membrane above the stricture occasionally becomes ulcerated, giving 
rise to fistula in ano ; in stricture of the urethra, there is sympathetic 
irritation of the rectum ; in that of the rectum, there is sympathetic 
irritation of the urinary organs ; and in disease of either canal, if not 
cured, death may be caused by gradual exhaustion, or by disease of more 
internal parts. 

Treatment. — The treatment of stricture of the rectum consists in 
attention to the condition of the bowels, and in the cautious use of the 
bougie, with the view of restoring the canal to its normal size. The 
rationale of the treatment of stricture of the rectum by means of the 
bougie, is the same as that of the similar treatment of stricture of the 
urethra. The object aimed at in both instances is, to excite absorption by 
pressure ; and in both great care must be taken not to use the instrument 
so often, or to allow it to remain so long as to produce irritation, which 



656 AFFECTIONS OF THE RECTUM. 

would aggravate the disease instead of alleviating. The simple intro- 
duction of the instrument is sufficient, and after the first operation, it is 
advisable to commence by inserting the bougie passed on the previous 
day, and immediately withdrawing it to introduce one of a larger size. 
This proceeding may be repeated every third or fourth day, or at longer 
or shorter intervals, according to the time necessary for the subsidence 
of all uneasy sensations caused by the previous operation. Sometimes, 
even after the most gentle and careful use of the bougie, it is necessary 
to have recourse to the hiprbath and to opiate injections, in order to 
allay the irritation produced. In some cases, the stricture has been 
divided by slightly notching it at different parts by means of a blunt- 
pointed curved bistoury introduced upon the finger, after which the 
bougie is employed for the purpose of dilatation ; but the very great risk 
of hemorrhage, the difficulty of checking it, and the danger of inflam- 
mation from wounds of the rectum, are serious objections to this pro- 
ceeding, which should only be resorted to in extreme circumstances, and 
then with the utmost possible caution. 

II. MALIGNANT STRICTURE OF THE RECTUM. 

The principal points in which the symptoms of this affection differ 
from those of the former are, that they are much more severe ; there is 
a constant dull shooting pain in the part affected, and in the back, 
extending down the limbs ; there is an extremely offensive discharge of 
blood and matter from the part ; ultimately the power of retaining the 
contents of the bowels is lost : and the symptoms affecting the urinary 
organs are much more distressing. The patient loses flesh and strength ; 
his countenance assumes a yellow appearance, characteristic of malig- 
nant disease ; and he presents the other symptoms of constitutional 
cachexy. The rectum is very irregular on its internal surface, and is 
usually affected along a considerable extent. Palliation is the only 
treatment the disease admits of. 



657 



CHAPTER XXI. 



AFFECTIONS OF THE EYE AND ITS APPENDAGES. 



OPHTHALMIA. 

All inflammatory affections of the eye-ball and conjunctiva are com- 
prehended under the general term, Ophthalmia. 

INFLAMMATORY AFFECTIONS OF THE CONJUNCTIVA. 

Of conjunctivitis, or inflammation of the conjunctiva, there are several 
varieties, of which the principal are, 1. Simple, 2. Pustular, 3. Ca- 
tarrhal, 4. Purulent, and 5. Strumous conjunctivitis. 

I. SIMPLE CONJUNCTIVITIS. 

This affection Is by some authors described under the more general 
term, ophthalmia simplex. 

Symptoms. — The principal symptoms are, pain of a sharp pricking 
character, a distressing sensation of heat and stiffness, a feeling as if 
sand or some other extraneous matter were lodged on the surface of the 
membrane, intolerance of light, and lachrymation ; and on opening the 
eyelids, the conjunctiva is found to present a red appearance of a scarlet 
tint, with a peculiar arrangement of the vessels, which requires to be 
carefully noticed for distinguishing inflammation of the conjunctival 
covering from inflammation affecting the deeper textures of the eye. 
The arrangement of blood-vessels characteristic of this affection is called 
reticular, and is represented in the accompanying drawing. The ves- 
sels are superficial, large, and tortuous in their course from the orbital 
circumference of the membrane towards the margin of the cornea ; they 
can be drawn aside or moved by dragging the eyelids with the finger, 
or by communicating movements to the 
membrane ; they anastomose very freely Fig. 255. 

with each other, and produce a beautiful 
web-like, or network appearance. In 
very severe cases the minute vessels be- 
come so much distended as to make the 
reticular arrangement less distinct, or al- 
together imperceptible ; and in place of it 
the membrane exhibits a uniform florid 
hue, with a very irritable appearance. 
There is slight febrile action in severe 
cases, but in others there are scarcely any 
constitutional symptoms. 

Causes. — Both the predisposing and ex- 
citing causes are numerous. Among the 

former are disorder of the digestive organs, functional disorder of the 

42 




658 



PUSTULAR CONJUNCTIVITIS. 



skin, and derangement of the general health however induced ; and of 
the latter some of the most common are, exposure to cold winds, 
atmospheric changes, inversion of eye-lashes, direct injury, lodgment of 
foreign matter, as dust or sand, between the eyeball and the eyelids, 
and the application of mechanical or chemical irritants. 

Treatment. — In the treatment of this, as of other forms of ophthal- 
mia, it is important to keep in view some rules which are universally 
applicable in all inflammatory affections of this organ, namely, to re- 
move the exciting cause if still in operation, to guard against all new 
causes of irritation, either to the eye itself or to the system at large, to 
obviate if possible the predisposing cause, which may be derangement of 
the functions of an organ remote from the eye, to exclude the light and 
to give absolute rest, not only to the affected eye but also to the other. 
In many cases of simple conjunctivitis, attention to these rules is alone 
sufficient to produce the desired effect ; in other cases, it is requisite in 
addition to this to prescribe sometimes rest of body, low diet, aperient 
medicine, and cold applications over the eyelids, and sometimes local 
depletion followed by warm applications. Local depletion may be in- 
stituted either by leeches, — which should be applied, not to the eyelids, 
but around the eye, to the temple, the forehead, or the nose, — or by 
scarification of the conjunctiva of the eyelids, the efficacy of which in 
acute cases is often very speedily perceptible. The above treatment 
must not be too long continued, lest relaxation be induced ; nor is it 
suitable in those cases which from the commencement partake of a 
chronic character, and in which passive congestion constitutes the prin- 
cipal condition of parts. 

When acute symptoms have been subdued, counter-irritation to the 
temple or behind the ear, and the cautious use of some slightly stimu- 
lating lotion, together with constitutional remedies, constitute the proper 
treatment. 



I. PUSTULAR CONJUNCTIVITIS. 



Fig. 256. 



Synonyms and Symptoms. — This affection, — sometimes called con- 
junctivitis pustulosa, ophthalmia pustulosa, and ophthalmia phlyctsenodes, 
— commences with pain, usually very slight, but varying in degree in 
different cases, and attended with an uneasy sensation as if caused by 
an extraneous substance, and felt principally during the movements of 
the palpebrse. Intolerance of light is not usually a symptom of this 
variety. There is often a secretion which coagulates and causes the 

lashes to adhere together. The palpe- 
bral division of the conjunctiva is more 
red than is natural ; on the ocular por- 
tion there is increased vascularity at some 
part, and sometimes one plexus of vessels 
appearing, sometimes several, each having 
its base towards the orbit and its apex to- 
wards the cornea. Lymph is deposited, 
and in the lymph pus is formed constitu- 
ting a pustule, the most frequent site of 
which is over the junction of the cornea 
with the sclerotic coat. In many cases there is a deposit of lymph and 




CATARRHAL CONJUNCTIVITIS. 659 

serum, so that the affection presents the character of a vesicle instead 
of a pustule. 

Pustular conjunctivitis is chiefly met with in children and young per- 
sons, and more especially in those who are of a scrofulous diathesis and 
liable to derangement of the function of the skin, or of the digestive 
organs. 

Treatment. — When the disease is very acute, in addition to rest of 
the eye, restriction of diet, and purgation, local depletion is necessary ; 
but in the great majority of cases the observance of the general rules of 
treatment already laid down, together with the application of some 
stimulating or astringent lotion, will be found sufficient. Of the many 
applications of this nature the solution of the nitrate of silver, of the 
strength of from two to four grains to an ounce of water, answers as 
well as could be desired. 

III. CATARRHAL CONJUNCTIVITIS. 

Causes. — This disease is most frequently caused by atmospheric 
changes, and hence it is usually epidemic. Exposure to damp, to cold, 
or to night air, especially after being heated or while in a state of 
fatigue, as also the circumstance of the feet or extremities being cold 
and wet, are all known to be exciting causes of this most common of all 
the varieties of ophthalmia. 

Symptoms. — In addition to the usual local symptoms of catarrh, and 
in many cases the general symptoms of catarrhal fever, though there is 
frequently but little constitutional disturbance, the patient is affected 
with stiffness and heaviness in the palpebrse, reticular redness com- 
mencing on the palpebral portion of the conjunctiva, sandy pain, as it 
has been called, great lachrymation, adhesion of the eyelids in the 
morning, and a discharge of opaque viscid mucus which collects on the 
cilia during sleep, with aggravation of all the symptoms in the evening. 
In some though comparatively few instances, chemosis takes place to a 
considerable degree ; and in these circumstances there is ground for 
anxiety as to the condition of the cornea, as it may become the subject 
of ulceration, or its vitality may be endangered, partly by purulent 
infiltration between its lamellae in consequence of inflammation, and 
partly by mechanical pressure produced by great distension of the con- 
junctiva impeding the circulation. 

Treatment. — The constitutional treatment varies according to the 
state of the symptoms affecting the general system ; but in all cases the 
condition of the bowels and skin must be attended to, and a proper per- 
formance of the functions of those organs promoted. The chief part, 
however, of the treatment is local and of a stimulating nature ; and 
under such the disease in most cases very soon subsides. The treat- 
ment I have usually employed, and with most satisfactory results, is 
that recommended by Mackenzie, namely, scarification of the conjunc- 
tival lining of the palpebrse, when the chemosis is great and the dis- 
charge distinctly purulent ; the application of a few drops of the solu- 
tion of the nitrate of silver twice a day ; fomenting the eyelids several 
times a day with a collyrium composed of one grain of corrosive subli- 
mate, six grains of muriate of ammonia, two drachms of vinum opii, and 



660 PURULENT OPHTHALMIA. 

eight ounces of water, used slightly warmed, a few drops being put into 
the eye in mild cases, but injected over the eye in severe cases ; anoint- 
ing the margins of the eyelids every night at bedtime with a very small 
portion of an ointment composed of six grains of the red precipitate 
levigated to an impalpable powder and half an ounce of butter, for pre- 
venting the tendency to adhesion of the eyelids ; keeping the patient in 
a dark room, avoiding all cold applications, and in the chronic stage, 
when very obstinate, using slight counter-irritation. This last is, how- 
ever, required in comparatively few cases, as the symptoms generally 
yield very readily to the use of the other remedies. 

IV. PUF.ULENT OPHTHALMIA. 

Ophthalmia purulenta is the name given to a violent form of inflam- 
mation of the conjunctiva attended with a secretion of pus. It will enable 
us to describe more clearly this very distressing affection, if we treat 
separately of three' different forms of it, namely, 

Purulent ophthalmia in adults, 

Purulent ophthalmia in newborn infants, 

Gonorrheal ophthalmia. 

PURULENT OPHTHALMIA IN ADULTS. 

Symptoms. — One of the earliest symptoms is an itching sensation, 
owing, it is believed, to suppression of the mucous secretion, — a symptom 
which is well known to be one of the earliest effects of inflammation in 
a mucous membrane. Another early symptom is a painful feeling as if 
particles of sand or glass were lodged between the eyelids and the eye- 
ball. This feeling, which is often very severe, comes on very suddenly, 
and arises not from the presence of any extraneous matter, but from the 
dilated state of the conjunctival vessels. 

There is at an early stage considerable mucous secretion from the in- 
ternal surface of each eyelid. This soon becomes opaque, and then, 
very rapidly, purulent ; and when the eyelids are separated, it runs down 
the cheek, producing in many instances irritation and excoriation. In 
this variety of the disease there soon occurs very acute and continued 
pain, attended with a most distressing sense of fulness and tension ; 
there is also a sense of weight and stiffness, with great swelling of the 
palpebrse ; and the cilia adhere to each other, in consequence of the 
coagulation of viscid mucus upon them. The palpebral portion of con- 
junctiva is first affected, — it becomes exceedingly red and swollen ; great 
effusion takes place into its substance, as well as into the submucous 
cellular tissue and the other textures of the palpebrse, so that they 
rapidly become very much swollen and of a livid appearance, and are apt 
to become everted. The eyelids have at first a slight tendency to become 
inverted, but the great swelling and protrusion of the conjunctiva, which 
is forced out between the eyeball and the margin of the palpebrae, soon 
produce a tendency to eversion. At an advanced stage of the disease, the 
conjunctival covering of the palpebras often assumes a kind of granular ap- 
pearance, arising from the enlargement of the natural papillae. The ocu- 
lar portion of the conjunctiva becomes exceedingly red and swollen, effu- 
sion taking place to a great extent into its substance, and also underneath 



PURULENT OPHTHALMIA. 661 

it into the submucous cellular tissue, raising the conjunctiva considerably 
around the circumference of the cornea, and constituting the condition 
technically called Chemosis. The cornea becomes hazy, and afterwards 
opaque and dull in appearance ; and if the symptoms are not subdued, 
the haziness greatly increases, and the cornea soon loses its vitality and 
is wholly or partially destroyed, in consequence of its nutritious fluid 
being interrupted by the tension of the conjunctiva and the rapid deposit 
into the submucous cellular tissue. The patient suffers much from cir- 
cumorbital pain, as well as from the pain and other symptoms already 
mentioned as affecting the eyeball and eyelid. The constitutional symp- 
toms are at first those of inflammatory and afterwards those of irritative 
fever ; and their intensity is proportionate to the severity of the local 
disease. 

Causes. — There is little doubt that in some cases, even in this country, 
this very serious disease originates in atmospheric influence ; but for- 
tunately it is of comparatively rare occurrence, and of the cases that do 
occur, a small number only are produced by this cause. It is well 
known, however, that in some parts of the world, as in Egypt, a very 
alarming form of this disease has long prevailed at different periods, 
owing its origin to atmospheric influence. When the disease once takes 
place, it is very apt to be propagated by contagion ; and there is reason 
to believe that in confined and crowded houses, in certain situations, the 
disease may also be conveyed from one person to another, without the 
actual contact of matter with the eye, but by infection. In this country 
the majority of cases of purulent ophthalmia in the adult are produced 
by the contact of matter from the urethra, vagina, or an eye affected 
with the disease. 

Treatment. — The treatment of this highly dangerous disease must be 
exceedingly prompt, and proportioned in degree to the age and strength 
of the patient and the intensity of the disease. The constitutional 
treatment in the early stage consists in the employment of venesection, 
low diet, perfect rest, purgative medicines — sulphate of magnesia with 
tartar emetic being found exceedingly useful — together with calomel 
and opium until the system be slightly affected. The patient should be 
kept in a cool, dark, and well-ventilated apartment. The local treat- 
ment most useful in the early stage consists in local depletion by means 
of leeches around the orbit, but not to the eyelids ; depletion by scari- 
fication of the palpebral portion, and also by horizontal incisions in the 
ocular portion of the conjunctiva, the eyelids being kept separate to 
promote the depletion ; diligent fomentation of the eyelids ; great at- 
tention to cleanliness, and the frequent and effectual cleaning of the 
eyes. For this purpose a fluid must be sent between the eyelids and 
eyeball, by means of a small syringe, so as completely to clear away the 
matter, which collects very rapidly. A mild astringent should also be 
used two or three times a day : one of the most valuable remedies of 
this class is, the solution of the nitrate of silver in the proportion of 
three or four grains of the nitrate to an ounce of water, which gene- 
rally has in a short time a decided effect in diminishing the discharge. 
In the more chronic stage of the disease counter-irritation is very 
serviceable ; and more powerful astringents are often required, such 



662 PURULENT OPHTHALMIA. 

as a strong nitrate of silver ointment, or the solid nitrate of silver, 
applied with a pencil to the inside of the eyelids ; or when the dis- 
charge has ceased, and the object is to apply an astringent to the re- 
laxed conjunctiva, a few drops of the vinum opii are used with ad- 
vantage. 

PURULENT OPHTHALMIA IN NEWBORN INFANTS. 

Causes. — Ophthalmia neonatorum, or the purulent ophthalmia of 
infants, is in the great majority of cases caused by the contact of leucor- 
rhoeal, or in some instances of gonorrheal, secretion with the con- 
junctiva, during the passage of the infant through the vagina, and want 
of attention to the careful washing of the infant's eyes immediately after 
parturition. Sometimes, however, the disease is catarrhal, arising from 
the injudicious exposure of the child to cold air ; or it may be caused by 
the soap with which the child is washed entering the eyes ; or by the 
exposure of the eyes to a bright light. 

Symptoms. — This disease usually begins to show itself on the third 
day after birth, at which time the ciliary margins of the palpebrge are 
observed to be of a pinkish red colour and glued together by a concrete 
puriform secretion ; and if they be gently separated from each other, a 
little white matter escapes, and the conjunctival covering of the eyelids 
is extremely red, vascular, and- swollen. The palpebral portion of the 
conjunctiva is first affected, the ocular portion soon becomes involved, 
eifusion takes place into the subjacent cellular tissue, and chemosis is 
produced ; the palpebrae become much swollen, tense, and of a livid red 
appearance ; and the palpebral conjunctiva exceedingly tumefied, so 
that when the eyelids are separated, it is apt to project and cause ever- 
sion of the eyelids ; the discharge becomes very great and of a yellow 
colour ; if the disease be not checked, there is great danger of the 
cornea being either partially or totally destroyed, particularly when the 
chemosis is considerable, as this produces obstruction of circulation ; 
purulent matter is infiltrated between the lamellae of the cornea ; and 
the lamellae exterior to the pus giving way, the destruction spreads by 
ulceration. 

Treatment. — The treatment I have always adopted in this form of 
ophthalmia is recommended by Mr. M'Kenzie, namely, washing the eyes 
three or four times in the twenty-four hours with a tepid solution of one 
grain of corrosive sublimate with six of sal ammoniac in eight ounces of 
water ; applying once or twice a day a few drops of a solution of the 
nitrate of silver in the proportion of four grains to an ounce of water ; 
applying also to the edges of the eyelids at night, in order to prevent 
their adhesion, a small portion of the red precipitate ointment, prepared, 
as recommended by Mr. M'Kenzie, by mixing six grains of the red pre- 
cipitate carefully levigated into an impalpable powder with half an ounce 
of butter, the ointment being melted before being applied ; a small dose 
of calomel daily, from a quarter to half a grain ; occasional doses of 
castor oil, and slight counter-irritation behind the ears. 






STRUMOUS CONJUNCTIVITIS. 663 



GONORRHEAL OPHTHALMIA. 



There are no symptoms by which it is possible with absolute cer- 
tainty to distinguish gonorrhoea!, ophthalmia from purulent ophthalmia 
produced by atmospheric influence and other causes. The history of the 
case will afford ground for diagnosis ; and if there be very profuse dis- 
charge, if the eyelids be exceedingly swollen and livid, with much pain, 
and if one eye be severely affected and the other remain uninjured, there 
will be reason to conclude that the disease is gonorrhceal ophthalmia. 
In the other forms of purulent ophthalmia it is the rarest thing possible 
for one eye only to be affected, and in them the palpebral portion of 
conjunctiva is the first attacked ; but in this form the ocular portion is 
first affected, the disease extending itself very rapidly to the palpebral 
division, and it is seldom that both the eyes are involved. This disease 
is extremely rapid in its progress : the danger of loss of vision from de- 
struction of the cornea is very great ; and the symptoms must be 
promptly combatted by the treatment already recommended for purulent 
ophthalmia in the adult. 



V. STRUMOUS CONJUNCTIVITIS. 



This form of conjunctivitis is also called phlyctenular ophthalmia, 
ophthalmia scrofulosa, and conjunctivitis scrofulosa, from the circum- 
stance of its being induced by the peculiarity of constitution denominated 
strumous, or scrofulous ; and like many other scrofulous affections it is 
most frequently met with in children, and in persons under the age of 
puberty. 

Symptoms, — This affection is indicated by the symptoms of the ordi- 
nary varieties of conjunctivitis accompanied with the following pecu- 
liarities, namely, that the lachrymation is great, and the intolerance of 
light or photophobia quite disproportioned to the local signs of inflamma- 
tion. 

"From the intolerance of light the patient subject to this disease 
avoids the light as much as possible ; and children usually lie upon the 
stomach and bury the face in the pillow, or endeavour to exclude the 
light more effectually by the aid of the handkerchief or the hands, which 
they press closely on the affected organs. When exposed to the light 
for the purpose of examination, the head is immediately shrunk upon 
the chest ; but if the hands be withdrawn, the palpebrse are found closely 
compressed together, and they are corrugated by violent, and sometimes 
spasmodic action of the orbicular muscles. It is not unusual, further, 
to find the face distorted by the action of the other superficial muscles 
of this region, not connected with the eye. If the disease has been of 
long standing, the surfaces of the eyelids, and of the cheeks are fre- 
quently red and excoriated from the irritation of scalding secretion and 
pressure of the hands of the patient." 

The ocular and palpebral portions of the conjunctiva present nu- 
merous distended vessels, and the appearances usual to the common 
varieties of conjunctivitis ; but at the same time the local appearances bear 
no proportion to the excessive morbid sensibility of the eye to the light. 



664 AFFECTIONS OF THE CORNEA. 

The inflammation is very apt to give rise to pustules on the circumference 
of the cornea or near it, and also to ulceration of the cornea. 

Treatment. — This affection is always attended with derangement of 
some important function, most frequently of that of the skin or the 
digestive organs, and a principal part of the treatment consists in the 
employment of judicious means for promoting the proper performance of 
the functions generally, as well as the use of such means as in the par- 
ticular circumstances of the case may be suitable for scrofulous cachexy. 
Quinine is an invaluable remedy in this disease. The local treatment 
which has been found most useful is, slight counter-irritation behind the 
ear, preceded, if the action of the disease be very acute, by slight local 
depletion by leeches or scarification at a very early period ; the applica- 
tion of belladonna to the temple every night ; putting a few drops of a 
weak solution of nitrate of silver into the eyes once or twice a day ; 
keeping the patient in a dark room, and preventing him from keeping 
up the heat and irritation of the eyes by pressing them with the hand, 
or by lying on the face ; and paying great attention to cleaning the 
eyes. 

AFFECTIONS OF THE CORNEA. 
SCROFULOUS CORNEITIS. 

Causes. — This affection appears to arise in many instances from ex- 
posure to cold and wet ; in some cases from want of sleep ; in others 
from over-exertion of the eyes ; and sometimes it cannot be traced to 
any particular exciting cause. 

Symptoms. — It is principally found in persons of scrofulous diathesis, 
from eight to eighteen years of age, and is marked by the following 
symptoms : — a haziness, and in many cases an opacity of the cornea ; 
roughness, with more or less of a thickened and changed state of its 
epidermis ; redness on the surface of the cornea, presenting several 
varieties as to appearance, but in some instances so extensive as to have 
been compared to red cloth, and to have received the name of pannus ; 
slight sclerotic redness of a dull character, constituted by the dilation of 
small vessels, and having no white ring such as exists between the zonu- 
lar redness, and the circumference of the cornea in the inflammations of 
the deeper tissues of the eye. In cases of considerable standing the 
cornea becomes unusually convex, and sometimes even conical, with 
hydr ophthalmia, or a superabundance of aqueous humour. There is 
considerable lachrymation, especially on exposure of the eye to light. 
The globe of the eye is somewhat tender, and there is a slight degree of 
dull pain ; these two symptoms are usually of an intermittent character, 
and in some instances they >are severe and distressingly aggravated at 
night; in the great majority of cases, however, there is little or no pain, 
except at the commencement of the affection. Another peculiarity dis- 
tinguishing this disease from scrofulous conjunctivitis is, that whereas 
in the latter the intolerance of light is so excessive as to have been 
called photophobia, in this disease it is not usually felt to any great 
degree, though in some instances, especially where there is much redness, 
it is more painful. Patients have in many instances a sensation as if a 






AFFECTIONS OF THE CORNEA. 665 

foreign substance were placed on the conjunctiva. When the disease is 
severe, the vision is greatly obscured, so that sometimes objects cannot 
be perceived, and the patient is only able to distinguish light from 
darkness ; when it is of a milder character, there is but slight dimness, 
and objects are seen as through a very thin mist. The disease is slow 
in its progress, and is usually very obstinate : it is generally attended 
with other symptoms of scrofula and weakness of constitution, and with 
functional derangement of the skin or of some other part of the system. 

Parts chiefly affected. — The superficial parts, the epidermic covering 
of the cornea, and the parts immediately below it are chiefly involved, and 
opacity results from effusion of lymph ; but pustules in the first instance, 
and afterwards ulcers, are often formed, and although the disease is 
generally seated in the superficial parts, it may affect the whole sub- 
stance of the cornea, and extend to the iris, the sclerotic and choroid 
coats, and even to the retina itself. 

Treatment. — In this, as in every other form of scrofulous inflamma- 
tion, the constitutional treatment is of the greatest possible importance, 
the principal points aimed at being to correct the * functional derange- 
ment, to improve the general health, and to arrest the deposit of fibrin, 
by which the opacity is produced. These important indications the 
surgeon must endeavour to fulfil by such means as may be judicious and 
efficient in the particular circumstances of each individual case ; but as 
a general rule, the most valuable means are, good diet, pure air, quinine, 
and the careful use of mercury, carried only so far as very slightly to 
affect the system. That the two medicines, carefully and judiciously 
employed, are invaluable in the treatment of this disease, will be readily 
acknowledged by all who have tried them. The local treatment consists 
in the employment of depletion by leeches, when the symptoms are 
acute ; slight counter-irritation behind the ear, or on the back of the 
neck ; warm, and especially opiate fomentations ; smearing the parts 
round the eye with the extract of belladonna at bed-time ; and when the 
symptoms have become chronic, the daily application to the eye of a 
stimulant, such as the vinum opii. The vinum opii and red precipitate 
ointment are the most useful stimulants, but the former is in most in- 
stances much to be preferred. Local treatment, however, will be of 
little avail without the constitutional treatment proper for the scrofulous 
diathesis. • 



ACUTE CORNEITIS. 



Causes. — This disease sometimes comes on without any obvious cause ; 
sometimes it arises from direct injury, or from exposure to damp and 
cold ; and sometimes it is a consequence of inflammation of other tex- 
tures of the eye. 

Symptoms.— The principal symptoms are, haziness, or cloudiness, or 
opacity of the cornea ; lachrymation ; intolerance of light ; pain and 
tenderness in the eye, liable to exacerbations, especially at night ; pain 
throughout the orbit ; redness of the cornea, evidently owing to an in- 
numerable quantity of vessels. When the inflammation is not confined 
to the substance of the cornea, but affects also its conjunctival covering, 
a red zone may be seen, called by some the inner zone, placed over the 



666 AFFECTIONS OF THE CORNEA. 

circumference of the cornea, and obviously formed of a number of dilated 
vessels proceeding from the conjunctival covering of the cornea, and 
penetrating the substance of the cornea itself. There is in some cases 
another red zone, called by some the outer zone, of a crescent shape, 
corresponding to a part of the circumference of the cornea, having one 
aspect well defined, namely, that towards the sclerotic coat, but the other 
not distinct in consequence of its being lost in the inner zone. This 
outer zone is constituted by the vessels of the conjunctiva covering the 
part of the sclerotic coat where it overlaps the circumference of the 
cornea, as well as "by some of the vessels within the substance of this 
portion of the sclerotic coat. A point of great importance for diagnosis 
is to remember, that there is no intervening white ring between this 
red appearance and the circumference of the cornea, as there is in in- 
flammation of some of the deeper textures of the eye. 

The local symptoms, as the disease advances, vary according to the 
results of the inflammation. Of these some bave been already explained, 
and others will be mentioned in the description of the remaining affec- 
tions of the eye. 

Treatment. — The principal remedies are, mercury, antimonials, and 
other antiphlogistic measures, which ought to be promptly resorted to, 
and continued with energy proportioned to the urgency of the symptoms 
and the other circumstances of the case ; local depletion ; warm and 
opiate fomentations ; and, when the affection has become chronic, coun- 
ter-irritation, and the very careful application of stimulants. The treat- 
ment of some of the results of acute corneitis will afterwards be men- 
tioned. 

OPACITIES OF THE CORNEA. 

Opacities of the cornea differ from each other in the degree of density 
and opacity, in the situation, and in the mode of formation ; and the 
terms, nebula, albugo, and leucoma are used to distinguish the different 
varieties from each other. 

Nebula is the term used to denote the least degree of opacity, and 
includes only those cases in which the cornea is cloudy or hazy. Its 
symptoms are a cloudy appearance and an impaired state of vision. The 
opacity is insensibly lost in the surrounding portions, and its edges are 
consequently undefined. 

The term nebula is by some authors made to comprehend slight opa- 
city of the cornea from deposition between the laminae of the cornea, or 
from deposition between it and its lining membrane, or between it and its 
conjunctival covering, as well as from changes in the conjunctival cover- 
ing itself. It is here used in the sense in which it is employed by many, 
to denote the least degree of opacity depending on slight interstitial 
change in the conjunctival covering itself, or on very slight deposit 
between it and the cornea. This condition may result from slight in- 
flammation, either originating in the part or spreading to it from other 
textures ; and the inflammation may be excited by any of the usual causes 
of ophthalmia ; or it may be brought on and kept up by a granular con- 
dition of the palpebral portion of conjunctiva, or by inverted palpebrse, 
or by inverted eye-lashes. These last-mentioned conditions are frequent 



AFFECTIONS OF THE CORNEA. 667 

causes of nebulae ; and the state of these parts should therefore be care- 
fully observed, because if any such exciting causes be allowed to remain, 
no treatment will avail to remove the opacity. 

Albugo is the name given to opacity of the cornea, when it depends 
upon the effusion of lymph'tnto any part of the cornea or between it and 
its conjunctival covering, or when the effusion is so dense as to give it a 
white pearly appearance. The opacity is greatest at the centre. In- 
flammation of the cornea in any of its most common forms is apt to lead 
to albugo ; but phlyctenular pustule, and onyx, or abscess of the cornea, 
are very common sources of this affection, of which partial or com- 
plete obstruction of proper vision, and a pearly white opacity, are symp- 
toms. 

Leucoma is the name given to a third variety of opacity, which 
depends on an opaque dense cicatrix. If the continuity of a portion of 
file surface of the cornea be interrupted by ulceration, sloughing, or by 
a wound of considerable breadth, leucoma is constituted by the corneal 
cicatrix by which the part is healed. Leucoma is usually depressed in 
the centre, and presents a contracted and circumscribed appearance. 
By these peculiarities it is distinguished from albugo, and by its pearly 
white colour from nebula. When the leucoma is large and in the centre 
of the cornea, loss of vision is the result. 

Treatment. — The treatment of nebula and albugo is precisely the 
same, and consists in the removal of any exciting causes of inflammation, 
the subduing of the inflammatory action by the treatment formerly 
described, and when this has been effected, in the use of stimulants for 
the purpose of promoting absorption. The application chiefly employed 
for this end are, the solution of the nitrate of silver, the red precipitate 
ointment, the vinum opii, and a solution of corrosive sublimate in the 
proportion of a grain to an ounce of water. It is important to select 
the proper time for commencing the use of these stimulants, which is 
not until the inflammatory action has been subdued, but soon after, 
because up to a certain period there is a tendency to a partial ab- 
sorption of the deposits, which tendency seems to wear off in course of 
time. 

There is much less prospect of benefit from treatment in albugo than 
in nebula ; and in leucoma, properly so called, when of some standing, 
none whatever. But when opacity of the nature of nebula or albugo 
exists around a recent leucoma ; that is when slight deposit of lymph con- 
stituting nebula, or more dense and white deposit constituting albugo, 
surrounds the corneal cicatrix which forms the leucoma, the nebulous or 
albugineous opacity may improve under treatment, while the leucoma 
remains unchanged. 

ULCERS OP THE CORNEA. 

Corneitis, however induced, whether by inflammation originating in 
the cornea from any of the ordinary causes of corneitis, or from a foreign 
substance imbedded in the cornea, or by inflammation spreading from 
the conjunctiva or some other tissue of the eye, may give rise to ulcers 
of the cornea. These ulcers are divided into two grand classes, the one 



668 AFFECTIONS OF THE CORNEA. 

comprising those which at their commencement are comparatively super- 
ficial, and the other, those which extending deeper penetrate the whole 
thickness of the cornea. The difference between the two classes arises 
from the mode in which the ulcers originate, and the form of the in- 
flammation from which they result. * 

Ulcers belonging to the first class, namely, those which do not pene- 
trate the whole thickness of the cornea, may, like ulcers in other parts 
of the body, exist in different states. 

First. — It may be in the state of a simple healthy ulcer. If so, the 
pain is comparatively slight : the edges are not abrupt, but regular, and 
bevelled off; and the surface and circumference exhibit a nebulous ap- 
pearance, or slight opacity, from the necessary effusion of lymph upon 
and around the ulcer. 

Second. — It may be in the state of an inflamed ulcer ; in this case the 
pain, lachrymation, and intolerance of light are great ; the edges and sur- 
face are irregular ; the part has an extremely irritable appearance, and 
red vessels are observable on the ulcer and surrounding parts, with other 
marks of inflammation. 

Third. — It may be in the state of an irritable ulcer. There is in this 
case an entire absence of the ordinary characters of a healing ulcer ; 
the pain is intense ; the lachrymation great ; and the intolerance of light 
excessive ; the parts have an extremely irritable and inflamed appear- 
ance, but the pain and sensibility are disproportionate to the local symp- 
toms of inflammation, more especially if the proper means for diminish- 
ing the pain and promoting the healing of the ulcer be not adopted. 

Fourth. — It may assume the character of an indolent ulcer, exhibiting 
no nebulous appearance on the surface, no opacity around the edges, 
nor indeed any appearance of the necessary effusion of lymph ; but, on 
the contrary, presenting a cavity comparatively clear and transparent, 
as if a part of the cornea had been taken out, with very little appearance 
of vessels, attended with comparatively little pain. 

Fifth. — It may belong to the class of sloughing ulcers, if there be 
very severe accompanying ophthalmia, giving rise to great effusion and 
pressure on the surrounding parts. In this case the risk of sloughing is 
very great. 

Treatment. — If the ulcer belong to the first of these varieties, that is, 
if it be a simple healthy ulcer, all that is necessary is, to take precau- 
tionary measures that the healing process be not interrupted : these con- 
sist principally in the regulation of the bowels and diet, and the protec- 
tion of the eye from exposure to light or to any other irritating influence. 
If the ulcer belong to the second, third, or fourth variety, the indication 
is to convert it into a simple healthy ulcer ; and the means usually em- 
ployed for this purpose are,-r-if it be an inflamed ulcer, to subdue the 
inflammation by the local and general treatment proper for the ophthal- 
mia of which the ulcer is a result ; — if it be an irritable ulcer, to touch 
it every second, third, or fourth day, or as soon as the pain returns, 
with a solution of the nitrate of silver, which diminishes the pain in a 
most remarkable manner ; partly perhaps by forming a slight film on 
the surface, and partly by destroying the sensitive filaments of the nerves 






AFFECTIONS OF THE CORNEA. 669 

of the part ; — and if it be an indolent ulcer, to employ some of the sti- 
mulating local applications in common use, together with suitable con- 
stitutional treatment. 

In the case of a sloughing ulcer, the grand indication is to subdue the 
ophthalmia by which the ulcer is produced; and indeed this must in all 
cases be attended to, otherwise little benefit will accrue from any treat- 
ment instituted for the healing of the ulcer. If the ulcer be of some 
standing, counter-irritation is generally very useful ; suitable treatment 
must be employed for the condition of the general system attending the 
ophthalmia which gives rise to the ulcer ; the eyes must be kept at rest 
and protected from exposure to light or to any other source of irritation ; 
and belladonna should be applied to the temple and around the eye at 
night, more especially if the ulcer be deep, as a means of diminishing 
the risk of protrusion of the iris, should penetration of the cornea take 
place. In every instance healing should be attempted as speedily as 
possible, lest, the ulcer should become one of the second class, which 
comprehends all cases where penetration takes place through the entire 
thickness of the cornea. 

When an ulcer belongs to this class, the following are some of the in- 
conveniences and dangers which result. 

HERNIA CORNEiE. 

Hernia cornese is constituted by the protrusion of the membrane of 
the aqueous humour, with or without some slight deposit of lymph ; 
and when the perforation is not perfectly complete, a very thin lamella 
of the cornea is also protruded. The protruded portion presents the 
appearance of a small transparent vesicle, and proper proceeding in such 
circumstances is to cut off the small vesicle by a single cut of a pair of 
scissors, to touch the part with a finely-pointed bit of the nitrate of 
silver, to preserve the pupil dilated by the application of belladonna as 
a means of diminishing the risk of protrusion of the iris, and to endeavour 
by all judicious means to heal the ulcer. 

PROLAPSE OF THE IRIS. 

Another and a common result, when penetration extends through the 
entire thickness of the cornea, is prolapsus iridis, of which there are 
several varieties. When the protruded portion is small, it presents the 
appearance of a small black body, which from its supposed resemblance 
to the head of a fly, is termed myocephalon, from f/,u«a, musca, and 
xsoaXnj, caput; when it is larger and flatter, it is called clavus, from its 
resemblance to the head of a nail ; and when the iris protrudes through 
many different openings, the condition is called staphyloma racemosum ; 
the former term being derived from <r<r*<puXyi, a grape, and applied to 
various grape-like swellings on the front of the eye, and the latter from 
racemus, a bunch fir cluster. 

Treatment. — When the opening is very small and the protrusion to a 
very slight degree, replacement may be accomplished, if it be attempted 
very shortly after its occurrence, and before adhesions have taken place. 



670 AFFECTIONS OF THE CORNEA. 

It is useless, however, to employ a probe ; for, although the return 
should be effected, the withdrawal of the probe would certainly be fol- 
lowed by reprotrusion. The proper mode is to excite dilatation of the 
pupil by the very free application of belladonna to the temple and 
around the eye ; and by this means the two desirable indications, 
namely, to effect replacement, and to prevent reprotrusion, are some- 
times fulfilled. All judicious means should then be adopted for avoiding 
irritation, and for promoting the healing of the ulcer. When the open- 
ing is larger and the protrusion to a greater degree, or of some stand- 
ing, it may be impossible in consequence of adhesions to effect replace- 
ment ; but if it were possible, it would not be desirable, for the only 
means of preventing escape of the aqueous humour and consequent col- 
lapse of the eye, is by allowing the iris to remain in the wound and 
becoming adherent. The proper steps to be taken therefore are, to 
promote adhesion, to avoid irritation of the eye by exposure to light, or 
by friction of the eyelid on the protruded part, to apply belladonna to 
the temple and around the eye at night, to use the treatment suitable 
for any accompanying ophthalmia that may still remain, and when adhe- 
sions have taken place and cicatrization advanced, to destroy the pro- 
truded part by the slightest possible touch with a very pointed portion 
of the solid nitrate of silver. The local application employed in the 
first instance for diminishing the irritability of the ulcer and promoting 
adhesion, is the solution of the nitrate of silver, of the strength at first 
of two or three grains to the ounce, and afterwards gradually stronger, 
if necessary. The use of the solid nitrate of silver would be attended 
with considerable risk of increasing the size of the ulcer, and, therefore, 
the solution is preferred ; but after cicatrization has taken place, it may 
be employed in the solid form with the view and with the precaution 
above mentioned. 

CONICAL CORNEA. 

It is a remarkable fact that this singular affection of the cornea was 
never mentioned by any ophthalmic surgeon before the year 1766, when 
John Taylor described it in his " Nova Nosographia Ophthalmia." The 
"London Journal of Medicine," for May, 1850, contains a very in- 
teresting original communication on conical cornea, by W. White 
Cooper, Esq., Senior Surgeon to the North London Eye Infirmary; 
from which it appears that this affection is peculiar to the human 
species ; that it is limited to civilized races ; that it prevails most in 
warm climates and in warm situations, and becomes more and more 
rare as we approach the colder latitudes ; that it is rarer in Scotland 
than in England, and rarer in the north of England than in the south 
and west ; that Mr. Walker, of Edinburgh, did not meet with one case 
out of 7679 patients, at the Edinburgh Eye Dispensary; that Dr. Caden- 
head, of Aberdeen, has seen only three cases out of upwards of 8000 
patients under his care in the Aberdeen Ophthalmic Institution, and in 
the ophthalmic wards of the Aberdeen Royal Infirmary ; that Mr. 
Mackenzie, of Glasgow, has met with only four instances out of 15,924 
cases, treated at the Glasgow Eye Infirmary; whereas, returns from 



AFFECTIONS OF THE CORNEA. 



671 



China give twenty-two examples out of 6789 ; from Dublin, 10 examples 
out of 4050 ; and from Plymouth, 13 out of 5118 cases. 

The following is part of a table given by Mr. Cooper, to show the 
proportion of cases of conical cornea. 



TABLE SHOWING THE PROPORTION OF CASES OF CONICAL CORNEA. 





Total 
Cases. 


Conical 
Cornea. 




Total 
Cases. 


Conical 
Cornea. 


Glasgow Eye Infirmary. 

June 1824 to Jan. 1847 
Aberdeen Hospital and 

Eye Infirmary 
Edinburgh Eye Infirmary. 

Jan. 1842 to Jan. 1850 

Macao Hospital. 

1841 to 1842 . . . 
1844 to 1845 . . . 

St. Mark's Hospital, Dub- 
lin. 

1845 

1846 

1847 

Royal London Ophthalmic 
Hospital, Moorfields. 

1839 

1840 

1841 

1842 

1843 

1844 

1845 


15924 
8000 
7679 


4 
3 



Brought up . . 

1846 

1847 

1848 

Plymouth Eye Infirmary. 

1845 

1846 

1847 

1848 

1849 ....... 

Liverpool Eye Infirmary. 

1834 

1835 

1836 

1837 

1838 

1839 

1840 

1841 

1842 

1843 

1844 

1845 

1846 

1847 . 

1848 


42310 
7010 
7672 
8382 


40 
9 
5 
6 


65374 


60 


31603 


7 


936 

848 

918 

1203 

1213 


3 

3 
4 
3 


1288 
5499 


7 
15 


6787 


22 


5118 


13 


980 
1526 
1544 


2 
6 

2 


1770 

1986 
1965 
2186 
2189 
2230 
2186 
2224 
2244 
2287 
3078 
3462 
3510 
3721 
3798 


2 

4 




2 
2 
1 
3 
3 
2 

1 


4050 


10 


4891 
5355 
5528 
6085 
6572 
6874 
7005 


2 
10 
5 
7 

12 

4 


42310| 40 


38836 


20 



From this table it is evident that conical cornea is a very rare disease. 
I have seen but one case, and it was one of three occurring in the large 
experience of Dr. Cadenhead, who did me the favour of showing it to 
me ; a finer example it is impossible to conceive. It appears that Von 
Ammon was the first to affirm that this disease is sometimes congenital, 
and some other observers have since arrived at the same conclusion ; it. 
seems, however, to be very rarely congenital, to be rare in children and 
old people, and to develope itself most frequently about the age of 
puberty. 

Symptoms. — The cornea presents the appearance of a cone, and gene- 
rally, but not invariably, the entire cornea is affected ; the apex of the 
cone being usually at the centre, and its base at the circumference, cor- 
responding to the junction of the cornea with the sclerotic coat. The 
surface of the cornea, when examined by an unassisted eye, appears 
smooth and even, but under -a lens, as was first noticed by Sir David 



672 



AFFECTIONS OF THE CORNEA. 



Fig. 257. 




Brewster, it is seen to be broken up by elevations and depressions. The 

perception of distant objects becomes confused, 
and eventually is lost ; at the same time, small 
objects are with difficulty distinguished at a 
moderate distance, and, as the disease pro- 
ceeds, a nearer and nearer approximation of 
them to the eye is necessary, to enable the 
patient to distinguish them ; and, at last, they 
cannot be recognised at all. Before useful 
vision is entirely lost, patients can only per- 
ceive objects when held very close to the eye 
and to one side. It has been observed that 
before the change in the cornea is very much marked, there is an un- 
usual lustre and brilliancy of the eye, which, in a well-lighted room at 
night, has been compared to the sparkling of a diamond, and adds ex- 
ceedingly to the expression of the eyes. 

Causes.-— The recorded experience of several authorities, namely, of 
Dr. Farre, Mr. Tyrrell, Mr. Square of Plymouth, and others, leaves 
little doubt that in some cases excessive weeping has been the exciting 
cause to which the disease was traceable ; and it has been remarked 
that congestion of the eyes combined with compression of the globes, is 
highly favourable to the development of the disease. From the observa- 
tions of Dr. Fr. Jaeger of Vienna, of Mr. Mackenzie of Glasgow, of 
Dr. Jacob of Dublin, and of Mr. W. White Cooper of London, it appears 
that this disease, in some circumstances at least, is a result of true cor- 
neitis, more especially in persons of an enfeebled constitution with a low 
condition of nervous energy. The cornea being rendered opaque and 
enfeebled by the inflammation, yields in the course of time to the pres- 
sure of the contents of the eye, and the opacity disappears. In several 
cases in which opportunities have occurred of examining the state of the 
cornea after death, it has been found of the usual thickness at its cir- 
cumference, but very much thinner at its apex, and the laminae less 
movable than natural. For much interesting information regarding 
this disease, I beg to refer the reader to Mr, Cooper's valuable commu- 
nication above mentioned. 

Treatment. — If the views above stated be correct regarding the cause 
of this disease, the proper treatment consists, first, in the removal of the 
corneitis, and afterwards in endeavouring to prevent increase by the use 
of local stimulants, together with suitable treatment for the general 
health. Some ophthalmic surgeons have thought that this treatment, 
where it was not successful in diminishing, yet retarded the increase of 
the prominence. Dr. Pickford has published an account of cases in which 
relief was obtained by a course of purgatives and emetics. Tonics with 
counter-irritation, have also been used, and, some have thought, with ad- 
vantage. Removal of the crystalline lens has been resorted to, with the 
view of diminishing the refractive power of the eye ; but although in one 
case, operated upon by Sir William Adam, the sight was improved, still 
the proceeding has not been found useful. Mr. Tyrrell has in some cases 
had recourse to alteration of the position of the pupil, so that it may 
not be opposite to the part where the cornea is most changed. He effects 



AFFECTIONS OF THE SCLEROTIC COAT. 673 

this by puncturing, with a needle, the cornea near its circumference, be- 
tween the outer and under aspect of the eye ; he then introduces a hook 
through the wound, draws down the pupillary margin of the iris, and 
brings a small portion of it through the wound, so as to draw down the 
pupil ; and the object then is to obtain adhesion of the iris to the wound 
in the cornea. 

Mr. Tyrrell states his impression of the results in the following words : 
"The advantage gained is more than adequate to the risk incurred ; for 
in no instance has any evil followed, beyond the slight degree of inflam- 
mation necessary to repair the mischief occasioned by the operation." 

AFFECTIONS OF THE SCLEROTIC COAT. 
SCLEROTITIS, OR RHEUMATIC OPHTHALMIA. 

Causes. — This distressing disease is induced by atmospheric influences, 
as a blast of cold air ; exposure to cold and damp, or the passing from a 
warm room into the cold air ; and an attack of this form of ophthalmia seems 
to create a predisposition to a return of the disease. It rarely takes place 
either before the age of puberty or in advanced life ; but occurs in adults 
and in persons of middle age, and most frequently though not exclusively, 
in those who suffer from rheumatic affections. 

Symptoms. — The pain is of a severe, agonizing, dull, pulsative cha- 
racter, affecting not only the eye, but the temple and all the parts around 
the orbit, constituting what is called the circumorbital pain. It is at- 
tended with a most distressing sense of fulness in the eyeball and ten- 
derness on pressure, and has this distinguishing peculiarity, that although 
unceasing it is greatly aggravated during the night. There is redness, 
which on examination is found to be of a dull character, and formed of 
small vessels under the conjunctiva, not obedient to the movements of 

the conjunctiva ; and instead of being reti- 
Fig. 258. culated as in conjunctivitis, it is radiated or 

zonular. There is haziness of the cornea 
and dimness of vision ; and the movements of 
the pupil are sluggish. There is no lachry- 
mation ; on the contrary, patients complain 
of a feeling of stiffness and dryness ; there 
is little intolerance of light, and the pupil is 
but very slightly contracted. The disease is 
often conjoined with inflammation of the conjunctiva, constituting 
catarrho-rheumatic ophthalmia ; and in this case there is profuse lach- 
rymation, great intolerance of light, and the sandy pain. Occasionally 
it is attended with some degree of iritis, and in this state also there is 
intolerance of light, and the pupil is generally more contracted. A con- 
siderable degree of irritative fever usually accompanies this disease. 

Seat of the Disease. — The inflammation has its seat in the sclerotic 
coat and in the tunica albuginea ; but frequently other textures, such 
as the conjunctiva and iris, become also involved. 

Treatment. — In this disease constitutional as well as local treatment 
is necessary ; the former consisting, especially in severe cases, or where 
there is constitutional disturbance, in the employment of general blood- 




674 CHOROIDITIS. 

letting, purgatives, antirnonials, low diet; and calomel and opium at 
bedtime ; the latter, in the use of local depletion by leeches, warm 
fomentations, blister to the back of the neck, or behind the ear, and the 
application of belladonna to the temple and around the eye at night. 

CATARRHO-RHEUMATIC OPHTHALMIA. 

Causes. — The causes of this very dangerous and common compound 
form of ophthalmia are the same as those of Sclerotitis, namely, atmo- 
spheric influences. 

Seat of the Disease. — Both the sclerotic coat and the conjunctiva are 
involved, and are usually attacked simultaneously ; hence the disease is 
said to be a compound of sclerotitis and conjunctivitis. It very fre- 
quently extends also to the cornea and iris, producing results by which 
vision is in many cases greatly impaired, and in some instances entirely 
lost. 

Symptoms. — In this disease the patient has, as in cases of conjunc- 
tivitis, the sandy pain (as it is called), or the feeling of sand between 
the eyeball and eyelids ; reticular redness, constituted bj vessels mova- 
ble on moving the conjunctiva ; lachrymation ; discharge of mucus, 
very rarely of pus ; adhesion of the eyelids in the morning ; intolerance 
of light ; swelling of the palpebras, and sometimes chemosis ; and, as 
in cases of sclerotitis, the agonizing circumorbital pain, and pain in the 
eyeball ; a feeling that the eyeball is too large for the orbit ; the 
radiated or zonular redness, deep-seated, and formed by vessels which 
are not obedient to the movements given to the conjunctiva ; a feeling 
of stiffness and tenderness on pressure; and violent irritative fever. 
If there be chemosis, it may be impossible to perceive the radiated or 
zonular redness. The pain proceeding from the sclerotic coat, although 
unceasing, is greatly increased during the night ; the sandy pain is, on 
the other hand, greatest in the morning. The cornea is exceedingly 
apt to be involved, becoming the subject of ulceration, or of onyx or 
effusion of pus between its lamellae — a very alarming condition, as the 
pus of an onyx in this form of ophthalmia is very rarely absorbed. The 
iris also is very frequently involved ; its colour changing, the motions 
of the pupil becoming sluggish, and the pupil contracted. If. the 
disease does not subside, there is great danger of the pupil becoming 
obliterated. Such are some of the distressing results in unfavourable 
cases of this disease. 

Treatment. — In addition to the treatment for sclerotitis already 
described, it is necessary, on account of the affection of the conjunctiva, 
to resort to the remedies proper for conjunctival inflammation, namely, 
scarification of the conjunctiva over the sclerotic coat — and the greater 
the chemosis, the greater is the necessity for this proceeding — the use of 
the solution of the nitrate of silver, and touching the margins of the 
eyelids at bedtime with the ointment of red precipitate, prepared as 
formerly directed. 

CHOROIDITIS. 

Choroiditis, or inflammation of the choroid coat, may exist as a pri- 
mary and distinct disease, and occurs in adults, and most frequently in 




RETINITIS. 675 

females of a scrofulous constitution. This disease is one of the most 
dangerous forms of ophthalmia ; and the symptoms at first are by no 
means of a very urgent or striking character. 

Symptoms. — An important symptom of this disease is alteration of 
the colour of the white of the eye, the alteration being usually propor- 
tioned to the severity and advancement of 
the disease; the white of the eye is changed Fig- 259. 

to a bluish or purplish hue, produced by the 
choroid coat, shining through the attenu- 
ated parts in front of it. There is redness 
which presents the peculiarities of not being 
perceptible over the whole of the white of 
the eye, but confined to one aspect, and of 
having the appearance of being formed by 
a broad set of vessels branching out towards 
the conjunction of the sclerotic coat and the cornea. In the course of 
time protrusion takes place at the discoloured part. The cornea usually 
becomes slightly cpaque, but the opacity is generally confined to the 
aspect towards the protrusion. Displacement of the pupil is a remark- 
able symptom : and in some cases it occurs to such a degree as to bring 
the pupil nearly behind the corneal conjunction. Pain, in the early 
stage, is sometimes very slight, but when the distension and swelling of 
the eye become considerable, it is perfectly agonising in the eye, and, 
in most cases, over the side of the head also, constituting what is called 
hemicrania. There is intolerance of light and epiphora. 

The vision is very differently affected in different cases : in many 
instances it is impaired by dimness, before any other symptom is per- 
ceptible ; in some it is soon entirely lost ; and in others, it remains to a 
considerable degree for some time after the eyeball has become enlarged 
and its colour altered. The appearance of flashes or sparks of light 
called photopsia (from <&sj£, lux, and o?rTof/.ai, video), and that partial 
defect of vision called hemiopsia (from r^vs, semis, and oaro/xai), the pe- 
culiarity of which is, that only half or part of an object can be distin- 
guished at a time, are both often early symptoms. 

Treatment. — The principal remedies are early, profuse, and in some 
cases repeated, general blood-letting ; purgatives, which are especially 
serviceable ; antimonials, and the vapour bath; local depletion by leeches, 
which, in order to be beneficial, must be very copious : counter-irritation : 
and when the disease has become chronic, if the distension be great, 
paracentesis oculi through the sclerotic and choroid coat, in order to 
evacuate the watery secretion underneath the latter, and between it and 
the retina. When the active stage is over, the use of tonics, more espe- 
cially the preparations of quinine and iron, either alone or combined, is 
resorted to with advantage. 

RETINITIS. 

In the acute form of this awfully painful disease the outward ap- 
pearances of inflammation are not perceptible, until other textures have 
become involved along with the retina. 

The patient at first feels an unpleasant sensation of pressure and 



676 iritis. 

tension, which is soon succeeded by most excruciating deep-seated pain. 
The pain is pulsating, aggravated by the recumbent posture, by the 
motion of the eye, or by the least motion of the body ; it soon extends 
to the head, and becomes so great as to be almost intolerable, and some- 
times to produce delirium. The vision is very early diminished, and 
very quickly becomes more and more impaired, until it is lost. Intole- 
rance of light is an early symptom, which, however, usually subsides 
before the pupil becomes closed. The patient complains of a most dis- 
tressing and annoying sensation of fiery spectra, and I have known this 
symptom to continue even after the pupil became entirely closed. The 
pupil soon loses its black appearance, and closes without undergoing any 
alteration in its shape or situation ; but before it closes, the retina is 
perfectly insensible to light. The iris undergoes changes of colour, 
which will afterwards be mentioned. The cornea loses its shining ap- 
pearance, and the inflammation of the other textures of the eye becomes 
perceptible. In addition to these local symptoms the patient is dis- 
tressed with violent symptomatic fever. 

Treatment. — Profuse, early, and if necessary, repeated general de- 
pletion, purgatives, antimonials, and the use of mercury so far as to affect 
the system, are the general remedies ; and local depletion by leeches, 
rest of the eye, exclusion of light, counter-irritation and the application 
of belladonna, constitute the local applications ; and they require to be 
employed with the greatest promptness and followed out very ener- 
getically ; otherwise, total loss of vision is likely to be the result. 

IRITIS. 

Iritis, or inflammation of the iris, a very common affection, may be, as 
to its intensity, acute or chronic, — a distinction of great importance ; as 
to its origin, idiopathic or traumatic : and as to its cause it may be un- 
connected with any constitutional affection, or it may be induced and 
modified by some specific taint or diathesis, especially by syphilis, scro- 
fula, and the rheumatic and gouty diathesis. Though variously modified 
by these different constitutional causes, as inflammations of other textures 
often are, it is no doubt one and the same affection. 

There is always a tendency in this disease to affect also other tissues 
of the eye, such as the choroid, sclerotic, or conjunctival coats, or the 
cornea : but notwithstanding this well-known fact, it is perfectly certain, 
that in many severe cases, where other textures have become involved, the 
iris has remained the focus of the inflammation, and after the subsidence 
of the disease has been found the principal seat of the morbid changes. 

We shall refer in the first instance to the acute and chronic forms of 
common iritis, and then very briefly to the more important peculiarities 
of iritis when modified by a constitutional taint or diathesis. 

ACUTE IRITIS. 

Symptoms. — Pain in the eye is commonly one of the early symptoms. 
In some cases the pain is slight, in others severe ; and when the inflam- 
mation extends to the sclerotic coat, the patient suffers from circumor- 
bital pain increased greatly during the night : this, however, does not 




iritis. G77 

depend on the iritis. Zonular redness around the margin of the cornea 

is a very characteristic symptom. It is 
Fi g- 26 °- produced by minute, closely compacted 

vessels in the sclerotic coat, running in 
radii from the margin *f the cornea to- 
wards the orbital margin, deepest in 
colour close to the cornea. The extent 
and depth of colour are proportioned to 
the severity of the disease. Sometimes 
this zonular sclerotitis, as it has been 
called, is separated from the circumference 
of the cornea by a gray line, which in some instances encircles the 
whole circumference of the cornea, and in others only a part of it. The 
vessels of this zonular sclerotitis are not obedient to movements commu- 
nicated to the. conjunctiva ; but when the conjunctiva becomes involved, 
vessels of a much larger size are observable, having a reticulated 
arrangement and being obedient to the movements communicated by the 
finger to the conjunctiva, and similar to those se'en in conjunctivitis 
when that affection presents itself as a primary disease. Another symp- 
tom is dimness of vision increasing as the disease proceeds. For some 
time objects are seen as through a piece of gauze or a mist ; but the 
dimness may continue to increase until it ends in total blindness. Nu- 
merous gray or dark muscae are perceived, which indicate that the in- 
flammation has extended to the choroid coat, as will be understood from 
what has been previously mentioned. Intolerance of light is a usual, 
though not an invariable, symptom, and when present is accompanied 
with lachrymation. 

Change of appearance and discoloration of the iris are striking symp- 
toms. The first change is, that the iris loses its brilliancy and presents 
a dull appearance, " absorbing the rays of light instead of reflecting 
them," as an excellent author has remarked. The kind of discoloration 
varies according to the natural colour of the iris. If the iris be natu- 
rally gray or blue, it acquires a greenish hue ; if brown, hazel, or 
dark-coloured, it changes but little in the early stage of the disease, 
and afterwards acquires a reddish-brown tinge. These changes are 
caused by the increased vascularity and the deposition of fibrin into 
its substance or on its posterior surface. Other symptoms observable 
about the iris are, that the pupil becomes contracted, its motions slug- 
gish and eventually perhaps entirely lost. Lymph is effused on the 
margin of the pupil and into the posterior chamber, and sometimes into 
the anterior ; and there are adhesions of the iris to the capsule of the 
lens. The aqueous humour becomes turbid, and the cornea losing its 
sparkling appearance becomes cloudy and hazy. Such are the usual 
symptoms when the disease is confined to the iris, or when that texture 
is the focus of the inflammation ; but when iritis is accompanied with 
inflammation of other textures, as the choroid, sclerotic, or conjunctival 
covering, or the cornea, the symptoms will be mixed up with those of 
inflammation of the involved tissues. 

Treatment. — The principal objects aimed at by treatment are, to 
subdue the inflammation ; to prevent the effusion of lymph, and to pro- 
mote its absorption when effused ; to prevent contraction of the pupil, 



678 ieitis. 

and to promote its dilatation when contracted ; to prevent adhesions ; 
and in many cases to subdue the pain, which is sometimes exceedingly 
distressing. The best means for fulfilling these indications are, early 
general depletion in all cases where the inflammation is severe ; local 
depletion by meatfis of leeches ; antimonials ; the use of mercury, carried 
to an extent to affect the system, and that as speedily as possible ; 
this being the most valuable remedy of all not only for preventing the 
effusion, but also for promoting the absorption of lymph ; the applica- 
tion of belladonna to the temples at night ; counter-irritation by means 
of blisters behind the ear after depletion ; rest of the eye ; exclusion of 
light ; rest of body, and due regulation of the diet and of the bowels. 
Calomel is the preparation of mercury preferred, and for the purpose of 
diminishing the pain, as well as for other reasons, it is used in combina- 
tion with opium. 

CHRONIC IRITIS. 

Symptoms. — The principal symptoms are, a dull condition of the iris, 
slight change of colour, sluggishness in the movements, and eventually 
perhaps a motionless condition of the iris, with irregularity and thicken- 
ing of the edges of the pupil, adhesions to the capsule of the lens, and 
impairment of vision. From this it is evident, that for the purpose of 
distinguishing iritis from other inflammatory affections, the appearance 
of the iris, the state of the pupil, and the condition of the iris as to 
motion, are important points for observation. 

Treatment. — The indications of treatment are best fulfilled by the use 
of mercury, which, however, is given more sparingly than in acute iritis, 
and is often advantageously combined with tonics : and the application 
of belladonna round the orbit. In recent cases the benefit of giving 
mercury internally, together with the outward application of belladonna, 
is often very great ; the one remedy, by dilating the pupil, keeps up 
tension on adhesions that may have formed, while the other weakens 
them by promoting absorption. 

TRAUMATIC IRITIS. 

Traumatic iritis may be the result of wound of the iris or of the 
lodgment in it of some foreign matter, such as a bit of stone, metal, or 
some other hard substance. This variety is always acute, and in addi- 
tion to the usual symptoms of common acute iritis, there will be others 
varying in different cases according to the nature of the injury exciting 
the inflammation. The treatment, therefore, will comprehend the use 
of remedies suitable for both these classes of symptoms. If the irritant 
be very small, it should be allowed to remain, unless its removal could 
be very easily effected ; but when it is likely to cause destruction of the 
tissue, it should, if possible, be removed ; otherwise the remedies for 
subduing the inflammation will be used with little advantage. 

RHEUMATIC IRITIS. 

This form of iritis, which is for the most part caused by atmospherio 
changes, is sudden in its attack, and is characterized by changes, com- 
mencing at the edge of the pupil, and extending towards the circum- 
ference of the iris. These changes consist in alteration of colour, first 



iritis. 679 

in the lesser and afterwards in the greater circumference of the iris, 
contraction and irregularity of the pupil, with loss of its bright black 
colour, a retraction, or drawing back of the margin of the pupil, and a 
pressing forward of the iris at its ciliary circumference as soon as dis- 
coloration, a never-failing symptom of inflammation, has reached the 
greater margin. The pupil presents a grayish appearance as the disease 
advances, owing to the effusion of slight films of lymph, by which the 
irregular retracted margin of the pupil is apt to become adherent to the 
capsule of the lens. When the iris becomes adherent at one or more 
points of the capsule of the lens, it constitutes the condition termed 
synechia posterior ; and when the front of the iris becomes adherent to 
the back of the cornea, the condition is called synechia anterior. The 
pain in the eye, and the nocturnal circumorbital pain, are both distress- 
ing. There is at first great* intolerance of light, but as the disease 
advances, the vision becomes so much impaired, that in some instances 
patients cannot do more than discern the light. The iris in some ex- 
amples becomes irregular on its anterior surface from deposits, not only 
into its substance, but also on the surface. The deposits of lymph in 
the last-named situation sometimes present small eminences, the effusion 
being under the membrane of the aqueous humour, but in some cases, 
from the giving way of that membrane, the effusion is into the anterior 
chamber, constituting hyjoopion. Owing to deposits within and upon 
the iris, its natural brilliancy is lost. The presence of the above symp- 
toms with those of common iritis, and accompanied with the rheumatic 
diathesis, will enable the surgeon to form a correct diagnosis. 

The same remedies are employed as in common acute iritis ; and it 
may here be added, that the greatest caution is necessary after the use 
of mercury, as it greatly increases the susceptibility of the system to 
be affected by exciting causes of the disease : that the eye and head 
must be carefully guarded against changes of temperature during treat- 
ment ; that blisters to the back of the neck are particularly useful in 
this form of iritis, and that quinine is often extremely beneficial, espe- 
cially in scrofulous persons, and often also in others after depletion and 
the use of mercury. It is of the greatest possible importance for the 
cure of the local affection to institute treatment proper for the constitu- 
tional diathesis. 

ARTHRITIC IRITIS. 

Arthritic iritis, or gouty inflammation of the iris, is met with in 
persons who have suffered from gout, especially if they have been dis- 
tressed with dyspepsia or depression of body or mind, or have an en- 
feebled condition of the general system. In such persons this may be the 
primary and only affection of the eye, or it may be the form into which 
a common variety of ophthalmia degenerates. But in persons of here- 
ditary predisposition to gout, who have been troubled with symptoms of 
gastric or renal^ derangement, and whose constitutions are enfeebled 
by intemperance and other causes, it is believed that arthritic iritis may 
present itself as a primary disease before any joint has been affected with 

3 out \ 

This variety exhibits the general symptoms of iritis, but is charac- 



680 IRITIS. 

terized by a loaded state of the vessels of the conjunctiva : by a line of 
a bluish white colour at the edge of the cornea ; by the zonular redness 
being of a purplish hue ; and by the pain being of a severe racking cha- 
racter, greatly increased at night, with remissions but not intermissions 
during the day. These local peculiarities, the fact that the disease 
comes on without any known exciting cause, the peculiar tinge of the 
zonular redness, the history of the patient, and the state of his general 
health, will all assist in forming a diagnosis ; but as some of these local 
appearances are met with in old persons in common inflammation 
excited by cold, the surgeon should satisfy himself as to the exis- 
tence of an hereditary predisposition to gout, before giving a decided 
opinion. 

General bleeding and the free use of mercury, are not employed as 
the usual modes of treatment in this fori| of iritis, although cases some- 
times occur with a full pulse and a dry state of skin, in which bleeding 
is practised with advantage. These cases, however, certainly form the 
exception and not the rule ; and with regard to mercury, it is only in 
very severe cases that it is used, except as an alterative. And the 
reason of this practice, as regards both these remedies, will at once be 
evident when it is remembered that arthritic iritis is in general asthenic ; 
that it usually occurs in persons of an enfeebled state of general health, 
and that the local disease is not so much under the influence of pure 
antiphlogistic remedies as of those calculated to improve the general 
diathesis which originates and controls the local disease. Along with 
suitable means for preserving a proper condition of the secretions of the 
bowels and skin, local depletion, counter-irritation to the back of the 
neck, great attention to diet, the very free use of belladonna, local warm 
stupes medicated with belladonna or opium, the use of colchicum, or of 
colchicum with alkalies, or of iodine, or of quinine, or of combinations of 
these medicines, or of turpentine, and the employment of judicious means 
for improving the general health, are the remedies from which benefit is 
found to accrue. 

SYP HI L IT IC IRITIS. 

This is one of the most common varieties of specific inflammation of 
the eye, and, if neglected or improperly treated, it is most destructive 
in its results. Thus far authorities are perfectly agreed; but they 
differ on the question whether in this variety the general symptoms of 
iritis present any peculiarities which are really diagnostic. On this 
subject a great authority remarks, " The fact, however, that even di- 
rectly contrary appearances have been enumerated as diagnostic of 
syphilitic iritis, shows that to distinguish this species from the rheu- 
matic, something more must be taken into account than any differences 
which may be observed in the general symptoms of the disease." As 
characteristic of this variety, Beer reckons displacement of the pupil, a 
gradual movement of it upwards and inwards, and condylomata sprout- 
ing from the iris, of a reddish brown colour, growing occasionally from 
the margin of the pupil, and projecting from the plane of the iris. 
Others consider as characteristic symptoms the very abundant effusion 
of lymph or pus, and its arrangement in many cases, so as to form a 






IRITIS. 681 

brown irregular ring around the pupil, the thickened condition of the 
pupil, and the nodulated arrangement of the effusion on the surface of 
the iris : but the diagnosis is readily made out by the history of the case, 
and by the coexistence of other constitutional symptoms of syphilis. 
It is found in conjunction with papular, pustular, tubercular, and scaly 
eruptions, and with other constitutional symptoms, such as ulcerations 
of the throat, pains of the limbs, and swelling of the periosteum. The 
only reason that can be assigned for its occurrence is the contamination 
of the system by the venereal poison. 

The treatment which is followed with the most beneficial results in 
the great majority of cases, is the administration of calomel and opium ; 
and when these remedies are unsuccessful — which is very rarely the 
case, except when the system is too weak and irritable for the use of 
mercury in any form or combination — then reliance is to be placed 
chiefly on the iodide of potassium, either alone or in combination with 
sarsaparilla, or quinine, along with suitable means for improving the 
general health ; but after what has been already stated as to the con- 
stitutional treatment of secondary and tertiary syphilis, I hope it is 
unnecessary to say more regarding the treatment of this variety of 
syphilitic disease. Turpentine taken internally has been found useful 
in this and in some other inflammatory affections of the iris. 

SCROFULOUS IRITIS. 

Strumous iritis may occur as a 'primary affection ; or it may be 
secondary, as a consequence of scrofulous inflammation of the cornea. 
The inflammation is very apt to extend in scrofulous corneitis to the 
iris, and in scrofulous iritis to the cornea. The symptoms of the scro- 
fulous diathesis afford such ample means of forming a diagnosis, as to 
make it unnecessary to refer to any modifications of the general symp- 
toms of iritis in this exceedingly common variety. 

In the treatment of this, as of all other examples of scrofulous inflam- 
mation, it should be kept in view, not only that depletion is very unde- 
sirable in persons of a scrofulous diathesis, but also that scrofulous 
inflammation is much less susceptible of benefit by depletion than com- 
mon inflammation, and that the free use of mercury is far from favour- 
able in persons affected with this peculiarity of constitution. Cases 
sometimes occur of so acute a character that it is necessary to resort 
to local depletion and to the use of calomel and opium, so as very 
slightly to affect the system ; but the latter proceeding ought always to 
be avoided, except when it appears necessary in a very severe case in 
order to save the eye. The treatment generally consists in the use of 
gentle counter-irritation, rest of the eye, exclusion of light, the appli- 
cation of belladonna, alterative doses of a mild mercurial, the adminis- 
tration of sulphate of quinine, and in many cases of quinine, in very free 
doses with a small dose once a day of mercury with chalk ; and the use 
of all judicious and practicable means under the circumstances for the 
improvement of the general health ; for it is always to be remembered 
that scrofulous inflammation is more amenable to remedies for improving 
the general health than to pure antiphlogistics. Cases often occur in 
which, along with tonics and other means for increasing the general 



682 CATARACT. 

strength, slight local depletion is required. A difficulty presents itself 
in the treatment of scrofulous iritis from the circumstance that the con- 
dition of the eye renders it impossible to resort to all the means most 
calculated to improve the scrofulous diathesis. 

CATARACT. 

Definition. — The term cataract (derived from xara^Wtfw, to break, 
vision being broken or disturbed by this disease) is used to denote 
opacity, situated anywhere between the vitreous humour and the pupil. 

Classification. — All cataracts are divided into two grand classes, 
namely, the true, comprehending all those which have their seat in the 
lens, the capsule, or both ; and the spurious, comprehending those, the 
situation of which is external to the capsule. 

TRUE CATARACTS. 

True cataracts, when classified with reference to their origin, are ar- 
ranged into idiopathic, or those which originate spontaneously, and trau- 
matic, or those which arise from injury ; when with reference to their 
appearance, into milky, purulent, flocculent, radiated, amber, black, 
&c. ; and when with reference to their situation, or the particular part 
affected, into lenticular, capsular, and capsulo-lenticular. This last ar- 
rangement is the most important one in a practical point of view ; and 
for determining the kind of operative proceeding suitable, it is also 
necessary to attend to a division of lenticular cataracts based on consis- 
tence, namely, into hard and soft. 

Symptoms. — The symptoms of cataract have, by an excellent authority, 
been arranged into the subjective, consisting of certain feelings experi- 
enced by the patient, and -the objective, consisting of certain changes or 
conditions in the eye observed by the surgeon. The principal symptom 
belonging to the first class is impairment of vision : as this symptom is 
common to cataract, glaucoma, and amaurosis, its peculiarities in the 
case of cataract must for the purposes of diagnosis be minutely observed ; 
they are the following : 

At first the patient sees objects, as if a thin mist, a cloud, or piece of 
gauze, intervened between the object and the eye. In the earliest stage 
this symptom is only perceptible in a bright light ; and, consequently, 
during this period, although vision is impeded by mistiness in mid-day 
light, it becomes distinct in the evening, or in a room where the light is 
diminished by a curtain or thin blind ; and a patient in a room, having 
while he looks to the window a distinct perception of the cloud between 
the object and the eye, loses it completely, and sees objects clearly on 
turning his back to the window. The perception of mistiness is also re- 
moved by holding between the object and the eye apiece of stained glass, 
which diminishes the quantity of light. Other peculiarities are, that 
vision is more indistinct when objects are held directly in a line with the 
axis of vision than when they are looked at sideways or in a slanting 
manner ; and that the confusion of vision is removed by the application 
of belladonna around the eye. In this early stage, then, the perception 
of mistiness is lost, and vision becomes distinct in a dull light, or when 
the pupil is dilated by belladonna, or when objects are looked at obliquely 



CATARACT. 683 

or slantingly ; hence patients are observed at this period to diminish the 
light by shading the eye with the hand, and to hold objects above or be- 
low the axis of vision when they wish to see them with distinctness. As 
the disease advances, however, the defect of vision increases, and the 
dimness is perceived in all circumstances, though to a less degree under 
those conditions under which it was previously imperceptible : eventually 
useful vision is completely lost ; but the patient does not become blind 
so as to be unable to distinguish light from darkness, as in some of the 
diseases afterwards to be described. 

The explanation of the above-mentioned peculiarities is the fact, that 
in the great majority of lenticular cataracts, opacity commences in the 
centre, and gradually but slowly extends to the circumference ; and in 
the contracted state of the pupil, caused by exposure of the eye to a 
bright light, or when an object is looked at directly in front of the eye, 
the rays fall upon the opaque portion of the lens ; whereas, in a dull 
light, or when the pupil is dilated by belladonna, or when objects are 
looked at obliquely, the rays falling towards the circumference of the 
lens are transmitted by the transparent portion, and distinct vision is 
the result. 

In a very rare variety of lenticular cataract, opacity commences at the 
circumference, and in such cases vision is rendered more confused in a 
dull light, or by dilating the pupil. Two other points important to be 
kept in view for arriving at a correct diagnosis are, that objects which 
are seen are in no case iridescent, and that the obscurity does not vary 
on different days, but in similar circumstances remains constantly the 
same. 

Such are the subjective symptoms, as they have been called, or those 
referable to the feelings and perceptions of the patient. The principal 
objective symptoms, or those observable by the surgeon, are the 
following : — 

On examination, the pupil, instead of presenting its natural black 
brilliant appearance, is observed to be of a grayish or whitish colour, 
which, in the great majority of cases, is most distinctly seen in the cen- 
tre, and imperceptibly blends with the surrounding transparent structure. 
As the disease advances, this opacity increases in density, and extends 
more towards the circumference. It can be detected with the pupil in 
its natural condition ; but, for a thorough examination, the pupil should 
be dilated with belladonna. The colour and site of the opacity should 
be carefully observed ; in lenticular cataract, the site is immediately be- 
hind the pupil, whereas in some other affections of the eye, as for exam- 
ple in glaucoma, it is a considerable distance behind the pupil, appearing 
deep in the vitreous humour. In lenticular cataract, the dark shadow 
of the iris may be seen presenting the appearance of a ring surrounding 
the opacity. These peculiarities, if the form of the opacity be neither 
convex nor concave, and its appearance nearly uniform, indicate that the 
cataract is lenticular, and, if the colour of the opacity be amber or dark 
gray, that the lens is hard ; if it be light gray, that it is soft. If the 
form of the opacity be convex, the site of the cataract is the anterior 
portion of the capsule, and in that case it appears immediately behind 
the pupillary margin, and presents a dull white, never a glistening ap- 



684 CATARACT. 

pearance. If the opacity be concave, the posterior portion of the cap- 
sule is the site of the cataract, which will then appear at a considerable 
distance behind the pupil, and will be further distinguished by opaque 
streaks radiating from the centre. The iris retains its mobility in 
cataract, but does not in general exhibit any of that tremulous motion 
which is so often found connected with congenital cataract, where it is 
usually met with in combination with oscillation of the eye-ball. 

There is a mode of examination by the reflection of light, proposed 
by M. Sanson, and called the catoptric test, which should not be omit- 
ted, as it furnishes the means for diagnosis between cataract, glaucoma, 
and amaurosis. For the application of this test, the pupil should be 
dilated by belladonna, and the patient placed in a dark room. 

" When a lighted taper is moved before the eye of a healthy person, 
three images of it may be observed. First, the erect image, that moves 
upwards when the candle is moved upwards, and that is produced by 
reflection from the surface of the cornea ; secondly, another erect image, 
produced by reflection from the anterior surface of the crystalline lens, 
which also moves upwards when the candle moves upwards ; and thirdly, 
a very small inverted image, that is reflected from the posterior surface 
of the crystalline lens, and that moves downwards when the candle is 
raised upwards. Now in cataract, the inverted image is from the first 
rendered indistinct, and soon abolished ; and the deep erect one is soon 
afterwards abolished also." In glaucoma, the deep erect image is even 
more evident than in the sound eye, and it is only in the very advanced 
stage that the inverted image is obliterated. In amaurosis, all the 
images are as distinct as in the healthy eye. 

TREATMENT OF CATARACT BY OPERATION. 

As long as useful vision is enjoyed by one eye, it would be injudicious 
to resort to operation ; but when useful vision is completely lost, the 
cataract being what is called matured, the eye being in other respects 
perfectly sound, the general health good, any inflammatory tendency or 
plethoric state of the general system which may have existed having 
been removed, the stomach and bowels being in a proper state, the 
patient having been kept at rest for some days, the diet restricted, and 
a few doses of saline purgative medicines having been taken at intervals, 
recourse may be had to operation. It will not, however, be prudent to 
operate on the second eye, until some time has elapsed after the opera- 
tion on the first. 

We shall refer to three different operations for the cure of cataract, 
namely, the operation of ^Extraction, that of Displacement, and that of 
Division. As no one of these is of universal application, as each has its 
advantages, disadvantages, and dangers, and as each has its peculiar 
recommendations in certain circumstances, it is requisite that all three 
be distinctly understood. 

OPERATION OF EXTRACTION. 

This is particularly suitable for the removal of hard cataract ; and 
indeed it is the only operative proceeding proper for that purpose. It 
has this recommendation, that, when successful, it effectually removes 



CATARACT. 685 

the cataract ; but, unfortunately, there are various conditions both local 
and genera], of not unfrequent occurrence, which would render it so ex- 
tremely difficult or hazardous, that they are considered as decided con- 
tra-indications ; and this operation, therefore, is properly restricted to a 
limited class of cases. 

The local conditions which contra-indicate this operation even in cases 
of hard cataract, are the following : adhesions of the iris to the cornea, 
or to the capsule of the lens ; a small size of the anterior chamber, 
either from natural conformation or from the iris being pressed forward 
by a large, although hard lens ; so small a palpebral aperture as to 
render it impossible to expose the globe of the eye sufficiently ; a deep 
position of the globe in the orbit — a condition which, as well as that last 
mentioned, would prevent the surgeon from making the section of the 
cornea in a proper manner — preternatural contraction of the pupil, 
called myosis (from jxuu, occludo), and its remaining small after the ap- 
plication of belladonna ; a soft condition of the globe, which indicates a 
fluid state of the vitreous humour — a case in which an operation would 
be followed by the immediate or gradual escape of that humour, and 
consequent complete destruction of the eye — or a very unusual degree 
of firmness of the globe, which indicates a great excess of vitreous 
humour. Of the general conditions contra-indicating extraction, the 
principal are, a very inflammatory, or a very irritable system, either of 
which would be likely to induce inflammatory destruction of the eye ; a 
very feeble state of body, which would in all probability prevent the 
necessary process of adhesion ; cough, asthma, or any condition of the 
lungs or heart, attended with difficulty of respiration. Any of these 
last-mentioned conditions would be apt to cause escape of vitreous 
humour, or protrusion of the iris ; and, consequently, the operation in 
such cases would be very hazardous. 

Only two instruments are required for this very delicate operation, 
the knife and the needle, bent at the point and fixed in a handle, or the 
curette. The knife usually employed is that of Professor Beer, of 
Vienna. The pupil being very moderately dilated, the patient seated 
in the erect posture, and the right eye covered by a bandage, if the left 
eye is to be the subject of operation, the surgeon places himself in front 
of the patient, and proceeds with the operation. This has been divided 
into three stages ; namely, 1st, opening the cornea with the knife ; 2d, 
opening the anterior hemisphere of the capsule ; and 3d, the extracting 
the lens, technically called the exit of the lens. 

The assistant stands behind the patient, holding his head, opening the 
upper eyelid with the fore and middle fingers, and assisting at the same 
time in fixing the eye by gentle pressure on the globe. The surgeon 
then depresses the lower eyelid, and further assists in keeping the eye 
steady by the fore and middle fingers of his left hand, the middle finger 
resting on the caruncula lachrymalis. The knife being held as a pen, 
with the edge upwards, its point is inserted on the temporal side of the 
cornea, close to the transverse axis of the cornea, at the distance of 
about the twentieth of an inch from the sclerotic coat ; and lest the 
knife should be sent between the lamellae of the cornea instead of into 
the anterior chamber, it should, until it enters the anterior chamber, be 



686 CATARACT. 

held perpendicular to the surface of the cornea, as if the object were to 
send it against the iris. Penetration of the cornea having been 
effected — in other words, the point of the knife having been sent into 
the anterior chamber — the handle is then directed towards the temple, 
so as to make the blade of the knife parallel to the iris, and the knife is 
then steadily pressed on until it reach the point of exit, and counter- 
punctuation be effected ; then, the eye being still commanded by the 
surgeon, who now brings down his middle finger to the lower eyelid, and 
directs the assistant to remove the pressure from the globe, the knife is 
carried on until section of the cornea be accomplished. This finishes 
the first stage of the operation. 

The moment the section of the cornea is completed, the upper eyelid 
should be allowed to fall down, the eyelids to close, and the eye to rest 
for a few seconds. The errors to be guarded against during this stage 
are, sending the knife between the lamellae of the cornea instead of into 
the interior chamber, wounding the iris with the point of the knife on 
completing punctuation, injuring the nose by not holding the handle 
sufficiently back to the temple after counter-punctuation has been 
effected, wounding the iris by the edge of the knife in completing the 
section of the cornea, or in carrying the knife onwards to the point of 
exit, and attempting to complete the flap by cutting a flap either by 
raising the knife, or indeed by any proceeding except that of sending it 
directly onwards after effecting counter-punctuation. 

The sending the knife onwards completes the flap, whereas the conse- 
quence of endeavouring to cut a flap would be to separate the back of 
the blade of the knife from the uncut portion of the cornea below, thus 
allowing the aqueous humour to escape, and thereby causing the iris to 
fall forward on the edge of the knife. Too much pressure on the globe 
would also send forward the iris. 

The eyelids should then be gently opened, and the capsule divided in 
a crucial form by the needle or the curette, the greatest care being 
taken not to touch the iris. This finishes the second stage. The eye- 
lids should again be allowed to close for a few seconds, during which 
time the patient must be careful not to compress the eye by straining or 
pressing with the lids. 

The surgeon then raises the upper eyelid with the thumb of his left 
hand, directs the patient to look down towards his nose, and in the 
gentlest manner possible presses on the upper part of the eyeball, and 
thus dislodges the lens, sending it through the pupil into the anterior 
chamber, and thence through the section of the cornea, after which a 
•very accurate adjustment of the edges of the cut portion of cornea is to 
be effected, and the eyelids closed ; and this finishes the third or last 
stage of the operation. The pressure by which dislodgment is accom- 
plished must be applied with the utmost caution, and discontinued as 
soon as the greatest diameter of the lens is through the pupil, lest other- 
wise the hyoloid membrane should be ruptured, and the vitreous humour 
allowed to escape. Both eyes should be covered with a very light 
covering, consisting of not more than three or four folds of soft thin 
linen, secured by a single turn of a bandage or ribbon, to which the 
folds of linen should be fixed. By these appliances the eyelids will be 
preserved motionless and closed. The patient should be placed in bed, 



CATARACT. 687 

lying on his back with the head and shoulders elevated ; and this posi- 
tion must be continued for some days : he should be careful to avoid 
sneezing, or coughing, or holding down his head ; his food must be of 
the most unstimulating nature, and given for some days in extremely 
small quantity, and in such a form as not to require mastication ; every 
judicious means should be taken to prevent inflammation, or to subdue 
it if it should supervene ; the eyelids should not, if possible, be opened 
for five or six days ; the patient should be kept in a dark room, and 
every cause of excitement avoided ; and not before two weeks at least, 
even in the most favourable cases, should the eyes be exposed to the 
stimulus of light ; and even then, with the utmost caution, and only to 
a dull light. 



DISPLACEMENT. 



The operation of displacement, formerly called couching, the most 
ancient operation for cataract, should only be performed in cases of hard 
cataract, in which extraction is contra-indicated by some of the condi- 
tions already mentioned. We shall refer to two varieties of this opera- 
tion, namely, depression, and reclination ; the object aimed at in each 
being the removal of the opaque lens from the axis of vision. Each 
operation consists of three stages, the first and second of which are 
common to both, and shall therefore be first described ; and afterwards 
we shall explain the mode of proceeding in the third, stage of each sepa- 
rately. 

The instrument generally preferred for these operations is Scarpa's 
needle. 

The pupil having been dilated by belladonna, the patient placed on a 
low chair, with his head, upper eyelid, and eyes secured by an assistant, 
as in the operation of extraction, the surgeon seated on a chair higher 
than that on which his patient sits, holds the lower eyelid and the eye 
by the fore and middle fingers of one hand, takes hold of the needle as 
he would of a pencil with the right hand, if the operation is to be per- 
formed on the left eye, but with the left if on the right eye, and hold- 
ing it horizontally with the convexity upwards, inserts it about one-sixth 
of an inch behind the corneal conjunction, precisely in the central trans- 
verse axis of the eye, and gently sends in the needle until the lance- 
shaped part of it has passed through the choroid into the vitreous 
humour. This completes the first stage of the operation. The above- 
mentioned distance from the corneal conjunction is selected to avoid the 
ciliary processes on one hand and the retina on the other ; and the cen- 
tral transverse axis, to avoid the two branches into which the long ciliary 
artery divides about three-tenths of an inch behind the margin of the 
cornea. 

In the second stage, the point of the instrument is made to divide the 
whole posterior hemisphere of the capsule ; it is then brought under the 
lens into the posterior chamber, and the point of the needle, formerly 
turned forward to divide the posterior portion of the capsule, is, while 
in the posterior chamber, directed backwards, and the whole anterior 
hemisphere of the capsule is divided. This completes the division of 
the capsule, and the second stage of the operation. 



688 CATARACT. 

The third stage of depression is commenced by placing the concavity 
of the needle on the upper part of the lens, and then by gentle manipu- 
lation the cataract is pressed downwards, and a little outwards and 
backwards into the vitreous humour. The needle should not be moved 
for a minute or two ; and before withdrawing it, the operator should 
carefully observe that the cataract does not reascend, lest it should be 
necessary to depress it again. 

If reclination be the operation to be performed, the concave part of 
the needle is placed against the front of the lens, a little above its centre, 
and by gentle manipulation is made to fall backwards and a little down- 
wards, and outwards. It is thus made to recline or fall back, its anterior 
surface being turned upwards. 

The principle on which the operation of displacement is founded, is 
considered by some of the greatest authorities as essentially bad ; not 
so much on account of the cataract reascending, as of the occurrence, 
not very unfrequent, at length of chronic inflammation of the eye, dis- 
solution of the hyoloid membrane, and amaurosis, results of the presence 
of an undissolved cataract in the unusual situation into which it is sent 
by the operation of displacement. This operation, therefore, should not 
be resorted to, except when extraction is contra-indicated. 

OPERATION OP DIVISION. 

The operation of division, — named also the operation for promoting 
absorption, and the operation for dissolution of the cataract, — is suitable 
for cases of fluid, and also of soft cataracts, and may be performed by 
division either through the sclerotic coat, or through the cornea. 

The object aimed at in this operation is to submit the cataract to the 
influence of the aqueous humour, which has the property of dissolving 
it. The mode of admitting the humour into contact with the lens for 
the accomplishment of the desired solution, differs in the two varieties of 
the operation. Except in the case of fluid cataract, the operation re- 
quires to be performed more than once ; but, when properly performed 
in suitable cases, it seldom fails to produce the desired result. 

OPERATION OP DIVISION THROUGH THE SCLEROTICA. 

The patient should be as carefully prepared for this operation as for 
displacement, and the eyelids and eye secured in the same manner. 
The same instrument is used, and the operations are in all respects the 
same until the needle is introduced into the posterior chamber. The 
convexity of the needle should then, by a partial revolution on its own 
axis, be directed forwards, and in that position sent inwards, until it is 
distinctly seen through the pupil ; when by cautious manipulation the 
front of the capsule over a space rather larger than the natural size of 
the pupil should be cut into shreds. Complete mutilation of the cap- 
sule, to this extent, is desirable. Mere penetration would not be suffi- 
cient, as reunion might take place ; and, on the other hand, to destroy 
the whole anterior portion of the capsule would be imprudent, as the 
lens might then fall forward on the iris. If the cataract be fluid, it will 
escape into the aqueous humour, cause a cloudy appearance, and be 
ultimately absorbed, and no further operation will be required. The 



CATARACT. 689 

surgeon should content himself with the mutilation of the capsule at the 
first operation, and in two or three months the needle should be again 
introduced, and carried inwards in the same manner ; and then by 
gentle movements with the needle, part of the lens may be broken down, 
and if perfectly soft, be sent through the pupil into the anterior chamber. 
In using the needle to break down the lens, it is very necessary not to 
send its point too far back, lest the posterior portion of the capsule be 
wounded, which would lead to opacity, and thus constitute capsular 
cataract. 

Division through the cornea, named Jceratonyxis, is by many con- 
sidered less hazardous than division through the sclerotic coat, inasmuch 
as fewer coats are wounded. The pupil must be previously dilated ; the 
needle should be of a smaller size, having the round part, which is in 
the wound of the cornea during the last stage of the operation, of in- 
creasing thickness, so as to prevent escape of the aqueous humour. The 
needle should be introduced one-eighth of an inch from the margin of 
the cornea — the temporal aspect being in general the most convenient — 
and sent through the pupil. At the first operation,* the surgeon should 
not do more than effect mutilation of the capsule to an extent equal to 
the size of the pupil. In the course of a few weeks the operation may 
be repeated, and a portion of the lens having been broken clown by 
lateral movements with the needle, the fragments may be brought for- 
ward by movements of the needle, with its concavity forward. In this 
as in the former operation, care must be taken not to wound the pos- 
terior hemisphere of the capsule. 

Division by drilling. — This modification of the operation of division 
was first suggested and practised by Mr. Tyrrell, who considers it par- 
ticularly adapted for cases of capsular or capsulolenticular cataract, 
produced by extension of inflammation from the iris to the capsule, in 
which adhesions have been produced. A fine straight needle is sent 
through the cornea near its margin, and, passing through the pupil, is 
made to penetrate the capsule and enter the lens to the depth of about 
one-sixteenth of an inch ; the handle is then made to rotate between the 
finger and thumb, so as to make the point act as a drill, after which the 
instrument is withdrawn. The operation is repeated in the course of a 
few weeks, and on each repetition of it a new part of the capsule and 
the lens is selected for the drilling. 

SPURIOUS CATARACT. 

Spurious cataract is constituted by effusion of coagulable lymph, as 
a result of inflammation of the iris, and of the capsule of the lens. If 
the lymph have a flocculent appearance, it is termed flocculent fibrinous 
cataract ; if that of a small white clot adherent to the pupil, and gene- 
rally also to the capsule, the term is clotted fibrinous cataract ; if it 
consist of a bar extending across the pupil, it is called trabecular fibri- 
nous cataract ; if. purulent matter be entangled in the lymph, purulent 
cataract ; if blood be entangled in it, sanguineous cataract ; or if part 
of the membrane which retains the pigmentum nigrum become detached 
in consequence of injury, and adherent to the capsule which is rendered 

44 



690 GLAUCOMA. 

opaque by inflammation, induced probably by the same injury, it is 
termed pigmentous cataract. 

GLAUCOMA. 

Glaucoma (from /Xauxos, viridis) is the name given to an affection of 
the eye, in which a greenish appearance is seen on looking into the 
pupil. 

State of parts as ascertained by dissection. — The following are the 
abnormal conditions most frequently met with : no trace of hyaloid 
membrane ; the Vitreous humour pellucid, or slightly yellow, but in a 
fluid state ; no trace of limbus luteus, or of foramen centrale in the 
retina ; little or no appearance of the pigmentum nigrum ; the choroid 
coat of a light brown colour ; and the lens, although still transparent, 
or nearly so, of an amber, yellow, or reddish brown colour. The 
opinion entertained by some authorities is, that glaucoma originates in 
inflammation of the hyaloid membrane, that this inflammation ends in 
its destruction, and that this destruction produces a series of other 
changes in the eye. 

Symptoms. — Gradual loss of vision ; dilatation and sluggishness of 
the pupil ; a greenish appearance seated at a considerable distance 
behind the pupil, best seen on looking directly into the pupil, and dis- 
appearing entirely when the eye is looked at in profile ; whereas in 
cataract the opacity does not disappear when looked at sideways. Before 
vision is lost, it is assisted by a strong light ; and this is another diag- 
nostic symptom between glaucoma and cataract. The catoptric test 
also assists in forming diagnosis ; for in glaucoma the deep erect image 
is even more evident than in a sound eye ; and it is only in the very 
advanced stage that the inverted image is obliterated. 

It appears difficult to account for the greenish colour of a glaucoma- 
tous eye. On this symptom Mr. Mackenzie says, " The glaucomatous 
lens, viewed in its natural situation, seems of a greenish, sometimes of 
a deep sea-green colour. Remove it from the eye, the greenness is lost, 
and on being viewed against the light, it is found of a deep amber 
colour. The lens then, and the vitreous humour, which is also often 
yellowish in glaucoma, probably absorb the violet and blue rays of the 
light entering the eye, leaving the yellow and green rays but little 
affected, whence may result the green appearance of the humours. It 
is not improbable, however, that the appearance presented in advanced 
cases of glaucoma is not to be ascribed entirely to a reflection of the 
green rays of light from the amber- coloured lens, but partly to a reflec- 
tion from the choroid at the bottom of the eye, that membrane being no 
longer capable of exercising its proper function from the defective state 
of the pigmentum nigrum. There is no green surface in the human eye 
to reflect the light of that colour, as there is in the eye of the sheep ; it 
must then be either in its passage into the eye, or in its reflection out 
of it, that it acquires the greenish hue ; and the part most likely to 
affect it in this way is the lens. Were it proved that the retina, which 
is naturally somewhat bluish, supported by a choroid destitute of pig- 
ment and a whitish sclerotica, reflects the light forward into the eye, of 



AMAUROSIS. 691 

a bluish colour, then one of the principal phenomena of glaucoma might 
be regarded as no longer difficult of explanation. In confirmation of 
this, if the lens is removed in this disease, or sinks to the bottom of the 
dissolved vitreous humour, the green appearance is almost entirely 
lost." 

Treatment. — It is only at the very commencement of this disease that 
any benefit can be afforded by treatment under the use of local deple- 
tion, counter-irritation, mercury in a mild form, rest of the eye, and the 
employment of the remedies suitable for the rheumatic or gouty diathe- 
sis, if symptoms of either present themselves. In some cases, at that 
period, the symptoms of glaucoma seem to be retarded, if not improved ; 
but in a more advanced stage, or in the glaucomatous state which comes 
on occasionally at an advanced period of life, no treatment is of the 
slightest benefit. 

AMAUROSIS. 

Definition. — The term amaurosis (from afxau^ow, obscurare) is used to 
denote obscurity of vision depending on disturbance, or change in some 
part of the nervous apparatus belonging to the organ of vision, or com- 
municating with it, that is to say, in the retina, optic nerve, or brain. 

Synonyms. — It is the gutta serena of the Arabians. Some of the 
many other terms which have been employed to denote this affection are 
amblyopia (from u^QXvg, ohtusus, and owo^xt, video), cataracta nigra, and 
suffusio nigra. 

Proximate cause. — The principal causes of amaurosis, are structural 
changes in some part of the nervous apparatus connected with the organ 
of vision, occalioned by some grade of inflammation in the retina, optic 
nerve, or brain ; changes in the retina induced by inflammation, scrofu- 
lous or malignant disease ; pressure on its concave surface by vitreous 
dropsy; pressure on its convex surface by effusion from parts ex- 
ternal to the retina ; changes induced by pressure on the portion 
of optic nerve within the orbit, — a part which, although - seldom the 
subject of disease commencing in itself, is occasionally compressed 
by results of inflammation by tumours, or by aneurism within the orbit ; 
inflammation or congestion within the cranium, or products of inflam- 
mation having its seat in the membranes of the brain, or in the portions 
of brain connected with the organs of vision ; tumours ; extravasated 
blood ; and softening of parts of the brain connected with the optic 
nerve. 

Such are the principal conditions on which amaurosis depends : but 
any state which makes the retina incapable of receiving with correct- 
ness the impressions of external objects, or the optic nerve incapable of 
transmitting impressions received on the retina, or the portion of brain 
connected with the optic nerve unfit for receiving those impressions, may 
be a proximate cause of this disease. 

Predisposing and exciting causes. — The fact that several members of 
the same family have in successive generations become affected with 
amaurosis, is strong evidence that hereditary predisposition is one cause 
of it. Some of the most respected authorities are of opinion that the 
form of amaurosis which is most frequently observed to be hereditary, is 



692 AMAUROSIS. 

that which depends on organic disease ; that it is more frequently met with 
in elderly than in young persons, and in females than males ; that it is 
most common in individuals with black irides, and that it is seldom con- 
fined to one eye. Long-continued over-exertion of the eye, especially 
long-continued perception of minute or luminous objects, has often been 
found to be an exciting cause of this disease ; and the form thus induced 
is usually the congestive variety. This variety is most, common in per- 
sons with light coloured or blue irides, and it occurs in the majority of 
cases at an earlier period of life than that which arises from organic 
disease. Literary men, engravers, watchmakers, and tailors are often 
the subjects of this variety. Vascular fulness in consequence of the ar- 
rest of some inordinate discharge or long-continued evacuation, or in 
consequence of over-exertion, or the use of wine or spirits, furnishes in 
many cases an exciting cause. In some cases the disease has been 
known to be caused by wounds of the forehead or near the orbit, and 
not on the eye itself, and in others by a single injudicious exposure of 
the eye to an exceedingly bright light, the sensibility of the retina being 
thereby destroyed. In some instances injury and irritation of some of 
the branches of the fifth nerve have been found to be the exciting cause, 
the rationale of which cannot be easily explained ; and in others long- 
continued gastric and intestinal irritation, typhus fever, great exhaus- 
tion caused by some excessive evacuation or by long-continued discharge, 
and debility from great mental anxiety, have operated as exciting causes. 
These are some of the unfavourable influences by which amaurosis 
has often been induced, but in the majority of cases it owes its origin 
to the continual operation of several exciting causes. 

Symptoms. — These are numerous and varied. Of*the subjective 
symptoms, those which are referable to the feelings and perceptions of 
the patient, the principal are the following : — impairment of vision, or 
some defect in the perception of objects. The impairment may vary 
from slight weakness of sight — called by some, imperfect or incomplete 
amaurosis ; by others, amblyopia amaurotica — to total blindness, or what 
is called perfect amaurosis. Sometimes in the early stage the defect of 
sight is not permanent, but returns at regular or irregular intervals, con- 
stituting the amaurosis vaga of some authors. Nyctalopia, or day- 
blindness, and hcemeralopia, or night-blindness, are examples of periodic 
amaurosis. In general, however, the periodic soon changes into the 
permanent form. In some cases the failure of sight assumes the myo- 
pic or presbyopic form, that is, the person becomes short- or long-sighted. 
Both varieties are met with, but the latter is the more common. Occa- 
sionally, in the early stage, objects are seen covered with a dense mist, 
a symptom called visits nebulosus ; and in some instances this mist 
appears to the patient as a constantly-increasing cloud : in others it 
appears at first of a light gray colour, and afterwards like dense black 
smoke between the eye and the object. In imperfect amaurosis, objects 
sometimes appear disfigured (yisus defiguratus), lengthened, shortened, 
bent, and in some instances inverted. The flame of a candle sometimes 
appears very long, and, as it were, divided into several portions. Beer 
regards this as a very unfavourable symptom, his experience having led 



AMAUROSIS. 693 

him to conclude that it is indicative of disease of the brain. In a case 
at present under my observation, the flame of a candle appears to the 
patient elongated and very much bent, without being divided into diffe- 
rent parts. Other peculiarities are, that some patients see only half an 
object at one time ; this symptom is named visus kemiopia. Some see 
parts of an object, other parts being concealed from view ; for example 
in looking at a word, some syllables — or at a line, several words — are 
seen at different parts ; this is called visus interruptus. Others see 
objects only when held obliquely, or in certain directions ; this is termed 
visus obliquus. Such are the principal defects of vision ; but many 
amaurotic patients have illusive perceptions of objects, and these vary 
much in appearance. Sometimes the patient fancies he sees flies or 
gnats flying before his eyes ; these appearances are named muscoe voli- 
tantes ; and this peculiarity is called visus muscarum. Sometimes all 
objects appear as if obscured by a network or gauze ; a symptom termed 
visus reticulatus. This network usually presents a white, shining, sil- 
very appearance in dark places, or when black objects are looked at, and 
a dark appearance in light situations, or when white objects are looked at. 
Objects are sometimes seen of wrong colours ; this is called visus colo- 
ratus ; and in many examples of amaurosis, a very distressing symptom 
is the perception of fiery balls or bright flashes of light passing suddenly 
before the eye^when the eyelids are shut; this is called photopsia ; 
it is an early symptom, is most common in plethoric persons, and is 
usually attended with considerable alarm. Some patients, in the early 
stage, dread the light — a symptom called photophobia ; whilst others have 
what has been called " a thirst for light," and a desire for a great 
degree of illumination of objects. The above are the principal symp- 
toms referable to impairment and perversion of sight. 

Sometimes in amaurotic cases there is a feeling of weight about the 
eye ; sometimes pain in the eye and in the neighbouring parts of the 
face, in the brow, or in the head ; sometimes patients have an unpleasant 
feeling of dryness in the eye and nostrils ; and in some cases the dis- 
ease is accompanied with giddiness, dizziness, tinnitus aurium, and a 
sense of fulness in the head, aggravated by exercise and the horizontal 
posture. The seat and peculiarities of the pain, and the history of the 
patient's health, will furnish important information both for diagnosis 
and treatment. 

The principal objective symptoms, or those which are discoverable on 
examining the patient, are the following : — 

In the early stage the pupil is in general sluggish and limited in its 
motion, and, in the advanced stage, dilated and motionless. This, how- 
ever, is not invariably the case ; for in some examples of perfect 
amaurosis of both eyes, the pupils have been found to vary in size 
according to the degree of light ; and in others of complete darkness, 
where one eye only was affected, the pupil of the amaurotic eye has been 
found to change as in health, according to the degree of light admitted 
to the sound eye. This suggests the propriety of covering the sound 
eye, while the other is under examination. Generally, however, not- 
withstanding the above peculiarities, the early and advanced stages are 
attended with the conditions of the pupil already mentioned. In some 



694 EXTIRPATION OF THE EYE. 

instances the pupil has its natural black appearance, more especially in 
cases depending on affections of the brain ; but more commonly it has 
somewhat of a cloudy or glaucomatous appearance. The patient does 
not converge his eyes towards objects placed before him. The applica- 
tion of the catoptrical test should never be omitted ; it shows the three 
images as in a sound eye. There is a vacant expression and a peculiar 
stare about the eye, together with an uncertainty in the movements of 
the patient, and a peculiarity of gait quite characteristic of the affec- 
tion. By the above-mentioned symptoms amaurosis may be readily dis- 
tinguished from cataract and glaucoma. 

Cases of complete amaurosis occasionally occur, in which very few of the 
ordinary symptoms are present. A striking example of this fact occurred 
in a patient under my own care about ten years ago, Mr. Watt, guard 
of the Defiance coach, then running between Edinburgh and Aberdeen. 
He had perfect amaurosis of his left eye ; and the only symptoms were 
total blindness of the eye, dilatation of the pupil, and a motionless con- 
dition of the iris. The history of this case is somewhat remarkable. 
"When giving Mr. Watt a prescription for some temporary derangement 
of his bowels, I observed, while he was sitting with his face to the window 
in a bright light, that the pupil of his left eye was exceedingly dilated, 
and that the iris was perfectly motionless. Not knowing that he was 
not aware of the state of his left eye, I asked him how l%ng it was since 
he lost the sight of his left eye ? His reply was, " Lost the sight of my 
left eye, sir ? I have not lost the sight of my left eye." I requested him 
to close his right eye ; and on recovering from his confusion and alarm 
at finding that he was totally blind of one eye, his first exclamation was, 
" That is a most alarming discovery, sir, you have made ; and how long 
is it, sir, since I lost the sight of my left eye ?" That I told him was the 
question I wished him to answer. I was in the habit of seeing Mr. 
Watt for several years, and his eye remained in the same state, and he 
had no uneasy sensation about the head or eye, or any symptoms what- 
ever referable to that region of the body, except those mentioned above. 

Treatment. — From what has been stated as to the exciting and proxi- 
mate causes of amaurosis, the principles of treatment applicable to its 
different varieties, and the suitable means for carrying them out, will at 
once be evident ; so that it appears unnecessary here to say anything 
further than that it is only at the very commencement of the incipient 
stage that any benefit can be expected from treatment even in the most 
favourable cases ; and that without relinquishment of the exciting cause 
and perfect rest of the organ, the best-directed treatment in other re- 
spects will be of no avail. 

EXTIRPATION OF THE EYE. 

The patient having been placed on his back, or in a chair with the 
shoulder and head raised and supported, chloroform having been admi- 
nistered, and the charge of the eyelids given to an assistant, whose duty it 
is to raise the upper eyelid by means of Pellier's speculum, and to keep 
the eyelids as much as possible out of the way of the knife during the 
cutting part of the operation, the operator disunites the eyelids from 



STRABISMUS. 695 

each other at the outer commissure by making a horizontal incision out- 
wards for about half an inch beyond the orbit, so as to allow the wide 
separation of the eyelids ; he the n passes a large curved needle armed 
with a doubje, waxed ligature, through the eyeball from side to side 
behind the cornea, and having cut off the needle, ties the two ends of 
the thick strong ligature together. As the object of this proceeding is 
to obtain a suitable means of applying traction to the eyeball while it 
is being detached from its surrounding connexions, the insertion of the 
needle should be so far back behind the cornea as to get hold of a part 
not likely to give way during the operation. Another mode of obtain- 
ing the command of the eye is by seizing it with a vulsellum. A scalpel 
or bistoury is then inserted between the eyeball and the inner canthus, 
and carried between the eye and under eyelid and round the ball, so as 
to divide the conjunctiva, and then by a few sweeps with the knife the 
muscles are cut through and the optic nerve divided, the eye being 
drawn by the ligature in various directions to give room for the move- 
ments of the knife. Two points should be attended to in the cutting 
part of the operation, namely, to leave as little as possible of the optic 
nerve in the orbit, and if the future use of an artificial eye be contem- 
plated, to leave as much conjunctiva as may be in a healthy state 
attached to the eyelids. Any hemorrhage may be easily commanded 
by the introduction of lint within the orbit. The edges of the wound 
made in disuniting the eyelids are brought together by a suture and an 
exceedingly light compress, and one or two turns of a roller are applied ; 
after which the patient should be kept very quiet, and every judicious 
precaution taken to prevent the occurrence of any high degree of inflam- 
mation. 

STRABISMUS. 

Definition. — Strabismus (from tf^agoj, qui est oculis distoriis) denotes 
that condition of the eyes in which the optical axes do not converge 
to the same point ; of this there are two forms, strabismus convergens, 
in which the eye looks inwards, and strabismus divergens, in which it 
looks outwards, the former being the more common. This affection 
depends on a disturbance of the balance of action of the recti muscles, 
which disturbance may sometimes be caused by excessive action of one 
muscle, but in most instances it probably arises from one muscle being 
enfeebled so as to be unable to resist its antagonist drawing the eye to 
the opposite side. This is rendered probable by the difference observed 
in the result when the internal rectus is divided by accident, and when 
divided in the operation for the cure of strabismus. In the former 
case the eye is turned completely outwards, whereas in the latter the 
external rectus usually brings the eye only into its proper position. 

Cases of strabismus proceeding from gastric, intestinal, or uterine 
derangement, from general debility, or from affections of the brain, are 
all unfit for operation ; as also are all cases in which the deformity is 
in consequence of opacity in the cornea, the distortion in such instances 
being an effort to remove the opacity from the axis of vision. 

Cases fit for operation are those in which the strabismus is confirmed, 



696 STRABISMUS. 

and in which there is no evidence of an exciting cause calculated to 
keep up or to bring back a disturbance in the equilibrium of muscular 
action within the orbit. In the chapter on Talipes some principles are 
mentioned for the guidance of the surgeon in the selection^ cases for 
operation for the cure of that deformity : many of the same principles 
are applicable to the selection of cases for operation for the cure of stra- 
bismus. 

The operation for strabismus is that which was first suggested by 
Stromeyer of Hanover, and soon afterwards practised by Diefenbach of 
Berlin, by Pauli of Landau, and in a short time by surgeons generally. 
Having performed it above one hundred times, I feel myself justified in 
stating my firm conviction, that if only fit cases are selected, it will be 
found most satisfactory in its results. The object of operation in strabis- 
mus convergens is to divide the internal rectus, and in strabismus diver- 
gens, the external. 

There are many varieties as to the instruments which have been em- 
ployed, and in some respects as to the mode of performing this little 
operation. 

With regard to instruments nothing more convenient need be desired 
than Pellier's speculum for keeping up the eyelid, a double hook in- 
vented for this operation, a forceps for raising, and a small pair of scis- 
sors for dividing the parts. 

The operation for strabismus internus may be performed in the fol- 
lowing manner. The patient being placed in a chair, the upper eyelid 
raised by Pellier's speculum, the under eyelid depressed, and the eye 
drawn outwards by means of the hook fixed in the conjunctiva fully a 
line behind the cornea, the speculum and hook being both held by an 
assistant, the operator pinches up the conjunctiva with the forceps, and 
makes a vertical incision about half an inch in length, and fully from 
two to three lines behind the cornea. By a few snips with the scissors, 
the tendon is exposed and divided ; and if, on removing the hook, the 
eye be slightly turned outwards at first, or the patient unable to turn it 
inwards to its former position, the operation may be considered perfectly 
satisfactory. 

I am sure that no better mode of performing this operation need be 
desired : but after dividing the conjunctiva, as already described, the 
operation may be completed by other modes ; for example, by raising 
the tendon with a small hook, bringing it very slightly forward, and 
dividing it with the scissors ; or a small grooved director and a small 
curved bistoury, both of which have been invented for this operation, 
may be used, the one for raising, and the other for dividing the tendon. 
Another mode of proceeding is to direct the patient to look outwards, 
and then to pinch up the conjunctiva with a forceps at once, and thus 
to dispense with the use of the small double hook for holding the eye. 
For obvious reasons, chloroform is not used in this operation. 

[Notwithstanding the simplicity of the operation, I have seen surgeons 
embarrassed for the want of a properly curved hook, with which to seize 
the muscle. The form recommended by Dr. Hays, of this city, I have 
found admirably adapted to the purpose. Dr. Hays gives the following 
description of the operation for strabismus internus. 



STRABISMUS. 



697 



" The patient is seated facing the light, on a chair without a back or 
on a stool, of such a height that his or her head will rest upon the breast 
of an assistant seated on an ordinary chair behind. The eye not to be 
operated on is to be bound up with a compress and bandage. The 
surgeon is to be seated on a common chair facing the patient. 

" The first step of the operation consists in the separation of the 
eyelids. This may be effected by the assistant, if he is a skilful one. 
For this purpose, if the left eye is to be operated on, he should raise 
the upper lid with the forefinger of his right hand, and depress the 
lower lid with the forefinger of his left hand. When the right eye 
is to be operated on, the upper lid is to be raised with the forefinger 
of the left hand, and the lower one depressed with the forefinger 
of the right hand. When the assistant cannot be depended on, the 
lids may be separated by a speculum ; and the best for this purpose 
we have seen., is the elastic steel wire speculum, represented in the ac- 
companying figure (Fig. 261). The two branches are to be pressed to- 

Fig. 261. 




gether, one end introduced under the upper and the other under the 
lower lid ; the force of the spring then separates the lids. An instru- 
ment, which also answers extremely well, has been devised by Drs. P. 
B. Goddard and W. W. Ruschenberger. It is made of silver wire, 
somewhat similar in form to that just figured, but it is constructed in 
two separate pieces, to one of which is attached a cylinder, and to the 
other a rod which slides in the former. When this instrument is ap- 
plied, and the branches separated, the friction of the rod against the 
cylinder will effectually resist any effort of the patient to close the lids. 
" The second step is the division of the conjunctiva. The 
patient being directed to turn the eye outward, the surgeon takes 



698 STRABISMUS. 

the small toothed forceps (Fig. 262), and seizes the conjunctiva, 

Fig. 262. 




about midway between the edge of the cornea and the caruncula 

lachrymalis, or rather a little 
Fig- 263 - nearer to the latter, so as to make 

a horizontal fold, which is then 
snipped across with the scissors 
(Fig. 263), close to the forceps, 
and between them and the cor- 
nea. When the left eye is ope- 
rated on, the forceps should be 
held in the left hand, and the 
. scissors in the right, with the 
probe-pointed blade upwards. 
When the right eye is operated 
on, the forceps are to be held in 
the right and the scissors in the 
left hand. If the first incision is 
not sufficiently large it may be 
extended above and below. A 
very good method of dividing the 
conjunctiva is with the small iris 
knife (Fig. 264). If the point of 
this be thrust through the fold 
of the conjunctiva from below 
upwards, with a single cut a suffi- 
ciently extensive incision may 
always be made. The conjunc- 
tiva being divided, the surgeon 
still holding the inner flap with 
the forceps and drawing it for- 
wards, is to separate it to a suffi- 
cient extent from the sclerotica, 
either by dissection with the 
scissors, or what is more con- 
venient, with one of. the small 
knives represented at p. 637, Figs. 
97 and 98. x Some surgeons ob- 
ject to this dissection under the 
belief that it subjects the patient to protrusion of the globe. We have 
never found this to result in any of our operations, and the dissection 
we recommend, much facilitates the subsequent steps of the operation. 
If blood now flows so as to obscure the parts, which does not often 

1 Lawrence on the Eye. 




STRABISMUS. 



699 



Fig. 2C5. 




happen, it is to be carefully wiped away with a small sponge, attached 
to the end of a probe, and tepid water. 

" The third step in the operation consists in the in- 
troduction of the blunt hook under the muscle. This 
sometimes presents difficulties to the inexperienced 
operator, which may be obviated by the use of a hook 
such as is represented in Fig. 265. It is formed of 
silver wire, as small as is consistent with the neces- 
sary strength, set in a bone handle, and is bent at the 
end so as to accommodate itself exactly to the curva- 
ture of the eyeball, and flattened at the point on its 
convex surface. The globe of the eye being a sphere 
of Jgths of an inch in diameter, the proper curve may 
be given to the hook by bending it on a cylinder of 
that diameter. The surgeon takes this blunt hook in 
his right hand when operating on the left eye, and in 
his left hand when operating upon the right eye, and 
applying its concave surface to the eye, he inserts the 
point beneath the conjunctiva, the handle being ele- 
vated, and pushes it backwards and downwards until 
the point is below the muscle and behind its insertion. 
He then rotates the instrument so as to turn the point 
backwards and upwards, and at the .same time de- 
pressing the handle, the point glides under the muscle 
and appears at its upper edge covered with the fascia 
which has been pushed before the instrument : some 
surgeons recommend that the fascia should now be cut 
so as to bring the point of the hook entirely out ; but 
this is not necessary. The muscle is now secure and 
the surgeon gently draws the eye outwards. 1 

" The last step in the operation consists in the divi- 
sion of the muscle. Incomparably the safest and best 
instrument for this purpose is the scissors represented 
in Fig. 263. The surgeon takes the instrument in the 
hand which is disengaged, so that the probe-pointed 
blade is towards the eye, passes that blade beneath the 
muscle close to the convex surface of the hook, and 
with a single cut divides the muscle. The patient may 
now be allowed to close the eye, and to rest awhile. 
After the lapse of a minute or two the lids should be 
separated and the condition of the eye examined. If 
the pupil is now in the centre of the orbit, and the 
patient cannot turn the eye horizontally inwards, the 
operation may be considered as complete. If the 
patient can, however, rotate the cornea into the inner canthus, it 
will be found that a portion of the muscle or some tendinous fibres 

1 Mr. T. Wharton Jones (Principles and Practice of Ophthalmic Medicine and Sur- 
gery, sect. 1996), recommends that the probe be passed under the tendon from above 
downwards, which seems to be preferable to the mode we have adopted, as it secures 
the ball from rolling upwards, during the division of the tendon with the scissors, and 
we shall try this method the first opportunity which presents. 



700 HORDEOLUM. 

remain to be divided. These are to be sought for with the blunt hook, 
and being raised on it, divided with the scissors. This is the part of the 
operation which requires most judgment and tact. If the fascia is too 
extensively divided the eye will become too prominent, or an external 
squint may result ; both of which are more disagreeable deformities 
than internal strabismus. On the contrary, if the muscle is not com- 
pletely divided with any adventitious fibrous bands which may exist, the 
squint will be but partially corrected, or when the muscle reunites may 
be reproduced. The muscle and fasciae should be simply cut across, 
and all dissection and separation of these parts from the globe of the 
eye avoided, except where the defect has resulted from repeated attacks 
of inflammation which have consolidated the cellular tissue, fasciae and 
muscles, giving rise to adventitious bands, &c. 

" No dressing is required to the eye operated on, except a rag wet 
with cold water. We recommend the patient to use it exclusively for a 
few days, and to turn it outwards, as far as possible, many times during 
that period, the other eye being kept bound up. Afterwards we desire him 
to look with both eyes at distant objects, so as to acquire parallelism of 
the eyes. This may be aided by holding a large book against the nose, 
and directing both eyes to some remote object. 

" We have never found any inflammation follow the operation re- 
quiring treatment ; but as a matter of precaution advise the patient to 
keep in a darkened room, to abstain from stimulating articles of food 
for two or three days, and to take a dose of salts the night after the 
operation. 

" This mode of operating causes very little pain, is perfectly simple, 
and three instruments, a pair of forceps (Fig. 262), a pair of scissors 
(Fig. 263), and a blunt-pointed probe (Fig. 265), are all that are abso- 
lutely required. The hooks employed by surgeons to evert the eye, 
always give pain, sometimes inflict injury, and are never necessary in 
cases suitable for the operation. 

" This method is, of course, not applicable to young children, but 
such, we conceive, to be very improper subjects for the operation. The 
deformity is of little consequence to them, and it is sufficiently early to 
attempt its removal when they have arrived at an age to appreciate 
the importance of the operation, and have acquired sufficient firmness to 
offer no resistance." — Ed.] 

AFFECTIONS OF THE EYELIDS, AND OF THE LACHRYMAL APPARATUS. 
HORDEOLUM, OR STYE. 

Hordeolum, a diminutive of hordeum, barley, is a name given to an 
inflammatory swelling near the margin of the eyelid on account of its 
usually being about the size of a small barleycorn. 

This affection is most commonly met with in young persons of a 
scrofulous diathesis, and it is most frequently brought on by exposure 
to cold and sharp winds, while the digestive organs are in a disor- 
dered state. Late hours and the use of spirits or wines are also ex- 
citing causes. 

At first the patient feels itching or slight smarting, but this soon 



OPHTHALMIA TARSI. 701 

gives way to pain, tenderness, tension, and great sensibility ; the 
swelling, which at first is of a bright red, gradually becomes darker and 
of a purplish hue ; the form becomes conical, and after pus has been 
formed, the apex presents a yellow colour. The swelling sometimes 
subsides without going on to suppuration ; but in most cases it suppu- 
rates and bursts, after which the swelling in general very soon subsides 
and heals up, but sometimes it degenerates into grando ; sometimes it 
returns in consequence of the whole of the matter not having been dis- 
charged ; and sometimes its healing is retarded by the disorganized 
cellular tissue being long in coming away. In many cases hordeolum 
consists of a small acute abscess caused by obstruction, retention of the 
contents and consequent inflammation of a meibomian follicle. 

With regard to treatment, the digestive organs should be carefully 
regulated, and a proper condition of their secretions promoted. A 
smart purgative, and cold applications in the incipient stage, will some- 
times stop the disease. When the inflammatory process advances, these 
must be changed for emollient applications, as fomentations, simple or 
medicated, or light poultices ; and when matter is'formed, the abscess 
should be opened : after which tepid water-dressings may be continued, 
and if the disorganized cellular tissue be long in coming away, the heal- 
ing of the part will be greatly promoted by touching the cavity with a 
small pencil of nitrate of silver. 

PHLYCTENULA, GRANDO, AND MILIUM. 

Phlyctenula, or a small semitransparent vesicle formed by the cuti- 
cle near the margin of the palpebra being elevated by a portion of 
serum, is often observed. Sometimes there is but one vesicle, sometimes 
there are several ; and they vary in size, but are not generally larger in 
volume than a small shot. The vesicle is apt to return, if it be merely 
opened ; but if a considerable portion of it be removed by a snip of a pair 
of scissors, there is very rarely any return. 

Small white superficial painless swellings, formed by the skin being 
raised by a suet-like substance, are often met with in the palpebrse. 
When such a swelling is about the size of an ordinary hailstone, it is 
called grando ; and when it resembles a millet-seed, milium. All that 
is necessary for the cure of these swellings is to open the skin and press 
out the contents. 

OPHTHALMIA TARSI. 

Synonyms. — Ophthalmia tarsi, psorophthalmia, scabies palpebrarum, 
and tinea ciliarum, are some of the various names given to a peculiar 
and generally tedious inflammation of the edges of the eyelids. 

Symptoms. — Itching and irritation in the ciliary margin are the first 
sensations : and as the disease advances, these give way to soreness, 
tenderness, and if the disease be acute, to sharp pain. Soreness, slight 
feeling of heat, and stiffness, however, are the chief sensations after the 
disease has existed for some time. According to the degree in which 
the conjunctiva participates in the inflammation, the patient complains 
of slight lacfcrymation, weakness, intolerance of light, and a feeling of 
sand between the eyeball and eyelids. The eyelids are glued together 



702 TRICHIASIS AND D ISTIC H I AS IS. 

in the morning by a viscid coagulated secretion ; and the incrustation 
thus formed binds the edges so firmly together that they cannot be 
easily separated without much bathing. By injudicious efforts to sepa- 
rate the eyelids without previous bathing, the eyelashes are often drawn 
out. The edges of the eyelids become thickened and red as the disease 
advances. Some of the cilia at their bases are enveloped in coagulated 
secretion, on the removal of which small ulcers or pustules are observa- 
ble. By the spreading of these ulcers, the margins acquire a raw ap- 
pearance, and the cilia become first irregular, "and ultimately almost 
entirely removed, the surface being raw, swollen, and thickened. The 
eyes have what has been called a bleared appearance. At first the 
edges are inflamed and affected with small pustules or ulcers ; thickening 
of the edges and irregularity of cilia next occur ; and lastly the cilia 
disappear, and the edges present a raw appearance. 

It is believed that generally the meibomian follicles are first affected ; 
but these, the roots of the eyelashes, the skin, and the conjunctiva, are 
all more or less involved ; and loss of the cilia, obliteration of the meibo- 
mian follicles, thickening of the palpebrae, and eversion of the lower 
eyelid, are some of the sequelae of this disease. 

The disease occurs in scrofulous subjects as a primary affection ; but 
it is more frequently a consequence of some other disease, such as 
measles, scarlatina, catarrhal or strumous ophthalmia. 

Treatment. — In the first stage, when acute, the treatment compre- 
hends slight depletion by scarifying the palpebral portion of the con- 
junctiva, warm emollient or opiate fomentations, and very careful bath- 
ing of the eyelids before opening them. The scabs must be cleared 
away with much caution from the bases of the cilia. At a more ad- 
vanced stage, the occasional use of astringent or stimulating collyria dur- 
ing the day, and the application of an ointment at night, constitute the 
proper treatment. The collyria generally preferred are weak solutions 
of sulphate of zinc, or nitrate of silver, or corrosive sublimate ; and the 
ointments, that of the carefully-levigated red precipitate of mercury 
mixed with fresh butter, or that of the nitrate of mercury very much 
diluted. 

The cilia sometimes require to be pulled out, when there is much ul- 
ceration around their roots ; and sometimes much benefit is derived from 
touching the small ulcers very gently with the nitrate of silver. All 
sources of local irritation must be guarded against : the functions of the 
skin, stomach, and bowels attended to ; and if the patient be scrofulous, 
the treatment for that diathesis must be instituted. When this disease 
has produced entire destruction of the cilia, with a thickened, florid, 
everted, and excoriated state of the edges of the eyelids, the condition 
receives the name of lippitudo. 

t TRICHIASIS AND DISTICHIASIS. 

Trichiasis (from Srgig, crinis) is a term used to denote a growth of one 
or more cilia towards the ball of the eye, and distichiasis (from 8tg } bis, 
and Cronos, or do) to denote a double order of cilia. 

These affections are caused by contraction of cicatrices consequent on 
ophthalmia tarsi, wound, ulcer, or some chronic affection of the palpebrae. 



E NT R OPIUM. 703 

They give rise to irritation, lachrymation, weakness of the eye, ophthal- 
mia, and, if not removed, a nebulous and vascular condition of the cor- 
nea, and ultimately ulceration and opacity of the cornea, and impair- 
ment of vision. 

The pseudo-cilia are always very fine and light-coloured, and in dis- 
tichiasis they never occupy the whole length of the eyelid, but appear 
at different parts. 

The inverted cilia should be pulled out by means of a fine forceps; 
and if, after careful and frequent repetition of this proceeding, they still 
reappear, the portion of the palpebral margin ' containing the pseudo- 
cilia may be carefully and smoothly cut off, and by that means a radical 
cure obtained. My limits will not permit me to describe other modes of 
treatment recommended for these distressing affections. 

ENTROPIUM. 

Entropium (from sv, in, and rgsitu, verto) is the name given to inver- 
sion of the eyelid, a condition which gives rise to — -lachrymation ; 
pain, especially in moving the eye ; irritation, as if produced by a 
foreign body ; intolerance of light ; inability to use the eye ; a degree 
of ophthalmia ; nebulous opacity of the cornea ; and impairment of 
vision. 

Causes. — Entropium most frequently depends on an extremely lax 
condition of the common integument, in consequence of which the orbi- 
cularis palpebrarum is unable to preserve the lid in its proper position. 
Sometimes it arises from contracted cicatrix of the palpebral portion of 
the conjunctiva ; a state which may follow ulceration, a burn, a wound, 
or destruction of the conjunctiva by an escharotic. A third condition 
which gives rise to it is thickening of the conjunctiva at the junction 
of the ocular and palpebral portions : as the swelling presses the eyelid 
from the ball of the eye and causing inversion. In some instances 
swelling causes eversion, as was mentioned in the description of some of 
the forms of ophthalmia, and in others it produces inversion. A fourth 
and very troublesome cause of entropium is contraction of the tarsus, a 
condition not unfrequently induced by a long-continued strumous 
ophthalmia. 

Treatment. — When entropium depends on the first or second of these 
causes, the treatment consists in pinching up a longitudinal fold of 
the integument of the eyelid, and removing it by the knife or the 
scissors, great care being taken to raise and remove the precise quantity 
of integument necessary for obviating inversion, without inducing ever- 
sion. When it proceeds from the third cause, the swelling should be 
combatted by treatment proper for the condition on which it depends. 
For the cure of entropium proceeding from contracted tarsus, various 
methods have been adopted. That practised by Mr. Tyrell, and uni- 
formly successful in his hands, is to make a perpendicular section of the 
lid, near its centre, through its whole thickness. The tension is re- 
moved, and the wound granulates and leaves but little deformity. An- 
other method is that recommended by Crampton, and adopted by many 
ophthalmic surgeons, namely, to make two perpendicular sections, one 
at each extremity of the contracted portion of the tarsus, to unite them 



704 AFFECTIONS OF THE LACHRYMAL APPARATUS. 

by a deep horizontal incision on the ocular aspect of the eyelid, and to 
suspend the palpebra for some time. The treatment for distichiasis has 
been instituted by some surgeons for the cure of this deformity. 

ECTROPIUM. 

By ectropium (from ex, and rgsTw, verto) is meant eversion of the eye- 
lid ; a state which gives rise to — epiphora, or watering of the eye, owing 
principally to the displacement of the punctum ; to irritation and exco- 
riation of the cheek, induced. by the secretion from the eye flowing over 
the cheek; to inflammation of the conjunctiva; and ultimately, if it be 
not removed, to structural changes both in the conjunctiva and the cor- 
nea. Exposure to atmospheric changes and lodgment of foreign matter 
are apt to induce inflammation in the palpebral and ocular divisions of 
the conjunctiva. 

Ectropium may proceed from acute or chronic enlargement of the 
conjunctiva lining the eyelid ; from relaxation and elongation of the 
tarsus ; from contraction of cicatrices on the face, from divisions of either 
canthus by wound ; or from combinations of these conditions. 

The enlargement of the conjunctiva is to be treated according to com- 
mon principles, and when other means fail and the condition becomes 
chronic, by excision ; elongation is most successfully treated by excision 
of a part in the form of a letter V ; contraction of cicatrices by removal 
of the cicatrices and transplantation of a portion of skin from the cheek 
or temple ; and division of canthus, by making raw edges, bringing them 
into apposition, and preserving them in contact by suitable retentive 
means until union be accomplished. 

AFFECTIONS OF THE LACHRYMAL APPARATUS. 
EPIPHORA. 

Epiphora (from s*]«, supra, and <ps£w, fero) is an overflowing or undue 
secretion of the tears, so that there is habitually a watery eye, and a 
frequent dropping of tears over the cheek. 

Epiphora differs from stillicidum lachrymarum, in that it consists in 
an over-secretion of tears, whereas the latter is a dropping of tears 
owing to some obstruction in the lachrymal apparatus for carrying them 
to the nose. 

As a disease in itself, epiphora is much less frequent than as a symp- 
tom of trichiasis, entropium, the presence of some foreign body under- 
neath the eyelid or in the conjunctiva, scrofulous ophthalmia, or some 
other disease of the eye or its appendages. It is not unfrequently a 
symptom of teething, of disorder of the digestive organs, of worms in 
the intestines, and of general debility ; and in some cases it appears to 
proceed from general irritability of the eye. 

From this statement it will be evident that it will seldom be necessary 
to prescribe for epiphora, but that in every case a minute examination 
should be made of the state of the eye and its appendages ; and that in 
some instances local, in some general, and in others local and general, 
treatment will be necessary for the removal of the condition, of which 
epiphora may be a symptom. 



AFFECTIONS OF THE LACHRYMAL APPARATUS. 705 



XEROMA, 

Xeroma, and xerophthalmia (from gigos, siccus, and «f/.//.a, visum, and 
ocpQu'kpog, ocidus) are terms used to denote the very reverse of the last- 
mentioned affection — a dryness of the eye instead of an excess in the se- 
cretion of tears. As a separate disease, I have not seen an example of 
this precise affection. There are, it is understood, two distinct varieties 
of it ; namely, lachrymal dryness of the eye, depending on a suppressed 
or deficient secretion of tears, and conjunctival dryness, arising from 
deficiency of the mucous secretion which lubricates the surface of the 
eye. It is met with in old persons sometimes alone, and sometimes in 
connexion with amaurosis ; and it is well known to be sometimes a symp- 
tom at an earlier period of life of amaurosis in its incipient stage. It 
is also said to take place as a consequence of disease of the lachrymal 
gland, as well as of great deficiency of nervous energy, and to be at- 
tended with this peculiarity, that the eye looks as moist and slippery as 
usual, although the patient complains of its being stiff and dry. 

DACRYOCYSTITIS. 

Dacryocystitis (from 5axgu, lachryma, and wwc, vesica) is the term 
given to inflammation of the lachrymal sac. Of this there are two vari- 
eties, acute and chronic. 

DACRYOCYSTITIS ACUTA, OR ACUTE INFLAMMATION OF THE 
LACHRYMAL SAC. 

Symptoms. — The symptoms are, pain of a deep-seated, throbbing, and 
lancinating character, principally in the situation of the lachrymal sac, 
but extending also to the surrounding parts ; swelling, commencing 
underneath the tendo palpebrarum, corresponding at first to the bounda- 
ries of the sac. The swelling is exceedingly tender to the touch, and 
hard at first, but afterwards becomes elastic, and ultimately acquires 
a feeling of fluctuation : it is very red and extremely painful, and as the 
inflammation extends to the surrounding parts, the redness becomes 
diffused, and the eyelids swollen and cedematous from effusion into the 
cellular tissue. The caruncula lachrymalis becomes inflamed, the puncta 
scarcely perceptible, and the transmission of tears through the lachrymal 
passages completely interrupted ; hence the stillicidium lachrymarum, 
and the dryness of the nostril on the affected side, to the membrane of 
which the inflammation also frequently extends. If resolution do not 
take place, and suppuration occur, the matter makes its way to the sur- 
face by ulcerative absorption, and is discharged. As the inflammation 
advances, patients usually experience pain not only in the situation of 
the lachrymal sac and surrounding parts, but also in the head ; and in 
severe cases they exhibit the usual symptoms of sympathetic fever. 
Fistula, permanent obstruction of lachrymal canals and duct, and exten- 
sion of the disease to the periosteum and bone, are the dangers to be 
apprehended in severe and neglected cases. The disease usually origi- 
nates in the mucous membrane of the palpebrse, and extends by conti- 
nuity of surface to the mucous membrane of the sac ; or commences in 
the mucous membrane of the sac without previous disease of the palpe- 

45 



706 AFFECTIONS OF THE LACHRYMAL APPARATUS. 

brge : but in some cases it arises from inflammation in the subcutaneous 
tissue, and thence it extends to the sac ; and in others, which fortunately 
are now of comparatively rare occurrence, the disease originates in the 
bone, and the soft parts of the lachrymal passages become secondarily 
affected. This comparatively limited class may be said to be in a great 
measure confined to scrofulous persons, who have been affected by syphilis, 
and whose constitutions have been injured and rendered irritable by the 
injudicious employment of mercury. 

Treatment. — In very mild cases, resolution is in the early stage often 
speedily obtained under the use of the antiphlogistic regimen, and of 
cold and evaporating lotions ; and in severe cases, suppuration is often 
averted by the employment of general depletion, purgatives, diapho- 
retics, low diet, together with local abstraction of blood by leeches, and 
the use of cold and evaporating lotions. When symptoms of suppura- 
tion appear, warm applications medicated with anodynes should be used, 
and as soon as matter is discoverable, the sac should be freely opened 
by a vertical incision commencing immediately underneath the tendo 
palpebrarum ; after which tepid water-dressings should be employed, 
and the parts syringed occasionally. By early, free, direct incision, 
structure may be saved and pain prevented. 

DACRYOCYSTITIS CHRONICA, OR, CHRONIC INFLAMMATION OF THE 

LACHRYMAL SAC. 

This disease — the most common to which the lachrymal passages are 
liable — occurs at all periods of life, but not so often in childhood as at a 
more advanced age ; persons of a scrofulous habit are especially subject 
to it, and it is more frequent in females than in males. 

Symptoms. — If the disease be chronic from the commencement, and 
not a result of acute dacryocystitis, and if it run its course, the princi- 
pal symptoms are the following : 

The first stage is characterized by a watery eye ; stillicidium lachry- 
marum ; weakness of the eye ; and impairment of vision from the accu- 
mulation of tears at the inner canthus. These symptoms are increased 
by using the eye, by looking at minute objects, or by exposure to cold 
and damp winds. There is slight redness, a feeling of uneasiness and 
fulness in the situation of the lachrymal sac, on pressing which the tears 
can be sent down through the nasal duct, and be made to regurgitate 
through the puncta : the tears are transparent, and not mixed with any 
muco-purulent secretion. The absence of muco-purulent secretion, the 
free passage for the tears through the nasal duct, and the power of com- 
pletely emptying the sac by pressure, are characteristic peculiarities of 
this early period. 

The next stage is attended with some increase of redness, of uneasi- 
ness, and of swelling ; the sac cannot be completely emptied by pres- 
sure, the nasal duct is generally obstructed, and the nostril dry ; and 
when the sac is pressed, tears and opaque muco-purulent secretion are 
seen to regurgitate through the puncta. This stage has received the 
name of Blennorrhea (from /3Xswa, mucus, and few, fluo), on account of 
the discharge of thick mucus along with the tears. 

In the third stage, all the symptoms are of a more decided character ; 



AFFECTIONS OF THE LACHRYMAL APPARATUS. 707 

the swelling increases, matter forms, and makes its way by ulcerative 
absorption to the surface. This is the stage of suppuration, and ulcera- 
tive absorption. 

After the discharge of the matter, the disease may subside, or it may 
again assume the characters of the previous stage called Blennorrhea ; 
or further collections may form, and make their way to the surface by 
fresh ulcerations of the parietes ; or the disease may degenerate into 
true fistula lachrymalis. 

In this disease a speedy cure is most desirable, not only for the same 
reasons which apply equally to other diseases, but also because, when it 
is of long standing, there is risk of the periosteum and bone becoming 
ultimately involved, constituting the condition called carious fistula. 
This risk is greater in scrofulous persons than in others. This condition 
of parts can be discovered by examination with the probe ; but generally 
manifests itself by the offensive smell of the discharge, as well as by 
other symptoms common to all sores which are situated over bones affect- 
ed with caries. 

There are the same varieties as to the structures' in which the disease 
commences in the chronic, as in the acute form of the affection; and 
here, also, the comparatively small class in which it originates in the 
bones, is composed chiefly of scrofulous persons who have become affect- 
ed with syphilis, and been injured by mercury ; and those in whom there 
is the greatest danger of the bones becoming secondarily affected, belong 
also to the same unhappy class. 

Treatment. — To improve the general health by suitable treatment is, 
in all cases and in every stage, a most important indication. In the 
first and second stages, the principal points of local treatment are the 
occasional emptying of the sac by gentle pressure, local depletion by 
means of leeches, cold applications to the inflamed parts, the application 
of a gentle stimulating ointment to the edges of the eyelids at night, 
bathing the eye at times with astringent collyria, and cleansing the 
lachrymal passages occasionally by means of Anel's syringe. The last- 
mentioned proceeding is important in all cases, except when the action 
is very acute, or the nasal duct completely obstructed. 

[When the lachrymal canals and sac are constricted by chronic in- 
flammation, they are to be treated upon the same principles upon which 
strictures are treated in other mucous tubes. Bougies properly made 
and carefully used, will be as serviceable as bougies in stricture of the 
urethra. Many surgeons have been disappointed with Anel's probes for 
dilating these passages. But by means of a series of metallic bougies 
made of silver wire, from No. 25 to No. 15, and having the extremities 
made without bulbs, but of the same form as that of other bougies, we 
know that the punta, canals, and sac may be dilated sufficiently for a 
style to be introduced and worn. — Ed.] 

In the stage of suppuration, the use of warm applications and early 
and free incision constitute the proper proceeding. Here, as in the 
acute variety of this disease, both suffering may be prevented and 
texture saved by early incision ; and no good can result, but much harm 
may, from delaying the adoption of this proceeding, after its necessity 
has become apparent. 



708 



AFFECTIONS OF THE LACHRYMAL APPARATUS. 



FISTULA LACHRYMALIS, AND OBSTRUCTION OF THE NASAL DUCT. 

The varieties with regard to the different tissues, in which the morbid 
action eventually terminating in fistula lachrymalis may originate, and 
the symptoms and anatomical conditions of that disease, may be clearly 
understood from what has been already stated. It is only necessary, 
therefore, here to remark that, although obstruction of the nasal duct 
may exist to some degree for a considerable time without fistula lachry- 
malis, yet it is always present in fistula lachrymalis, and indeed furnishes 
the condition which it is a paramount indication to remove, in order to 
cure the fistula ; and that, although in the early stage, this obstruction 
may for some time depend on congestion and inflammation, without 
much or any organic change, and may in such cases yield to remedies 
for improving the general health along with the use of local depletion, 
stimulating ointments, astringent collyria, and some of the mildest forms 
of counter-irritation, yet in the more advanced stage it depends on or- 
ganic changes caused by exudation into the submucous tissue, and the 
texture of the mucous membrane itself, and can be removed only by 
operation. 

The only instruments necessary for the performance of this little, 
neat, and very satisfactory operation are, a narrow straight bistoury, a 
silver probe, and a style. The patient having been seated on a chair, 
the operator makes an incision in the common integument, at the under 
border of the tendo palpebrarum, and sends the knife into the lachry- 
mal sac and the commencement of the nasal duct, by directing it down- 
wards, very slightly backwards, and a very little inwards. The knife 

Fig. 266. 




is then withdrawn, and the probe sent down through the canal into the 
nose, and on withdrawing the probe, the style is immediately lodged in 
the canal, when the operation is finished. I have, in several instances, 

[Fig. 2GG. From Jones, on Diseases of the Eye. — En.] 



AFFECTIONS OF THE LACHRYMAL APPARATUS. 709 

dispensed with the use of the probe, and sent the style at once into the 
canal on withdrawing the knife. There are three simple directions, at- 
tention to which will enable the surgeon to perform this operation very 
quickly and neatly ; namely, to introduce the knife at the under border 
of the tendo palpebrarum ; to hold the several instruments as much in a 
vertical direction as the forehead will permit ; and in sending them 
downwards, to keep them slightly backwards and inwards, close to the 
mesial side of the lachrymal canal, which can easily be found, as it is 
immediately behind the ridge, on the nasal process of the superior max- 
illary bone. If these directions be attended to, the instruments cannot, 
unless force be used, be sent into any part except the lachrymal canal. 
The broad little head of the silver style rests on the common integu- 
ment, and as it is made black, to a careless observer it looks like a little 
bit of black plaster below the inne'r canthus. The presence of the fo- 
reign body excites a degree of inflammation, in consequence of which the 
style ceases for a short time to be loose in the canal; but this soon wears 
off, after which the style should be removed every day or two, and the 
canal cleansed by means of Anel's syringe ; and when the surgeon is 
perfectly satisfied as to the permeability of the canal, and the sound con- 
dition of its lining membrane, the use of the style may be discontinued. 
After this, the opening generally heals up without interference ; if not, 
the gentlest possible touch with nitrate of silver, or a hot wire, will pro- 
mote occlusion. I have been much gratified with the result of this very 
satisfactory operation. To other modes of proceeding my limits will 
not permit me to refer. 



710 



CHAPTER XXII. 



AFFECTIONS OF THE NOSE. 



LIPOMA OF THE NOSE. 

To a hypertrophied condition of the common integument and subcuta- 
neous adipose tissue of the nose, the term lipoma of the nose is applied. 
These lipomatous enlargements of the nose seem to be restricted to the 
skin and subjacent tissue of the apex and alas ; which textures become thick- 
Fig. 267. 




ened and opened out. " The sebaceous crypts," Mr. Liston remarks, 
"are enlarged and distended with their secretion, some of them to a 
considerable degree, forming occasionally encysted tumours of the size 
of a garden pea ; the cellular tissue is loaded with serosity, and in some 
cases there is evidently fibrinous deposit ; the arterial capillaries are not 
much enlarged, though the veins on the surface sometimes are, giving 
to the tumour a blue and distended appearance, as when the part is de- 
pendent, or its circulation excited, or the return of blood prevented by 

Fig. 267. From Liston. 



AFFECTIONS OF THE NOSE. 



711 



violent exertion of the lungs, different parts become affected in succession, 
and the mass is made up of many growths from the point and sides, of 
various sizes, separated by fissures in which the sebaceous secretion 
lodges, often rancid and offensive." In lipoma of the nose, as in fatty 



Fig. 268. 



m 




tumours in other parts of the 
body, fatty tissue is the pre- 
vailing element. In normal 
fatty tissue there are vessels 
and fibres of areolar tissue 
in greater or less abundance 
between the true fat-cells ; 
and the same is the case in 
lipoma. In some instances 
the areolar tissue is very 
sparingly found, whereas in 
others it abounds, forming 
tough fibrous partitions be- 
tween the parcels of fatty 
cells. 

The swellings are pendu- 
lous and loose, very insen- 
sible, slow in their growth, 
of a purplish or livid red ap- 
pearance, as if produced by 
passive congestion ; and, al- 
though unattended with pain, 
create discomfort and annoy- 
ance by interrupting vision, interfering with the functions of the nose, 
rendering it difficult to take food or liquid with comfort, disfiguring the 
appearance, and in some cases confining the breathing when the patient 
is in a horizontal position. Removal is therefore to be desired, and can 
be effected without danger or difficulty : the cicatrix becomes ultimately 
firm and depressed ; and when completely removed, the swelling does 
not refurn. 

Until of late, surgeons generally appear to have been deterred from in- 
terfering with these lipomatous swellings of the nose, probably from a 
dread of hemorrhage. Some good cases, however, are recorded, in 
which the late Mr. Hey of Leeds, Mr. Barlow of Blackburn, M. Civa- 
dier, and M. Thuelot, have performed this operation ; and my late 
kind friend Mr. Liston operated on the patient from whom the accom- 
panying sketches were taken. By the kindness of the publishers of 
Liston's "Practical Surgery," I am enabled to give these sketches; the 
first of which conveys an excellent idea of this disease in a very 
aggravated form, and the second, of the very satisfactory result of the 
operation. 

Mr. Liston gives the following directions : — " An incision should be 
made through the diseased integument and cellular tissue in the mesial 
line, upon the cartilages of the apex and columna, not however so as to 



Fig. 268. From Liston. 



712 AFFECTIONS OF THE NOSE. 

injure them ; an assistant places his forefinger in one nostril, and the 
surgeon, seizing the mass either in his fingers, or with a small vulsellum, 
proceeds to dissect it off with a scalpel ; the incisions must be carried 
close to the cartilages of the abe, until the one side is cleared, the edge 
of the opening being well observed and not encroached upon. The 
assistant will give warning if the knife at any stage of the proceeding 
approaches his finger. The surface is trimmed a little, if occasion 
requires, with a thin, slightly curved or knife-edged scissors. A similar 
proceeding is observed on the opposite side, so as to make the part as 
symmetrical as possible." Any troublesome general oozing may be 
stopped by the assiduous application of pledgets of lint, moistened with 
cold water. When the discharge has ceased to be coloured, tepid water- 
dressings should be applied, and suppuration promoted. 

POLYPUS OF THE NOSE. 

Varieties. — The varieties of nasal polypi are, simple, cysto-mucous, 
fibrous, and medullary. Careful discriminations of these different affec- 
tions is very important, both for prognosis and treatment. 

SIMPLE POLYPUS. 

Synonyms. — Simple polypus, simple mucous, mucous, common and 
gelatinous, are the names given to this mild and most common form. 

Characters. — Simple polypi occur at all ages, but are most common 
at the middle period of life ; they are seldom single, and rarely con- 
fined to one nostril; they grow from the investing membrane of the 
nostrils, and almost invariably from that portion of it which covers the 
superior turbinated bones ; sometimes, however, especially in children, 
they originate from the part of the membrane which covers the inferior 
turbinated bone, but never from the septum. On two different occa- 
sions I found, at post-mortem examinations, polypi of this class origi- 
nating from the mucous membrane covering 
Fig. 269. the side of the nostril, immediately above 

the inferior turbinated bone. The patient 
has a constant sense of stuffing ; preter- 
natural discharge of mucus ; a feeling of 
cold in the head ; a frequent desire to blow 
the nose, and a difficulty in doing so ; im- 
pairment or entire loss of smell, often also 
of taste ; and at an advanced stage, when 
the tumour presses back upon the mouth 
of the eustachian tube, there may also be 
loss of hearing : then also speech is af- 
fected, becoming indistinct and snuffling. 
The symptoms are aggravated during damp 
weather. After they have attained some considerable size, the polypi 
can be brought into view on blowing the nostril ; they become so large 
as to fill up the whole of it, and often make the under part of the nose 
present a broad appearance, giving an unpleasant expression ; but 

Fig- 269. From Liston. 




AFFECTIONS OF THE NOSE. 



713 



never, like some other polypi, cause separation of the bones. They are 
of a yellow gray colour, have little sensibility, produce no pain, and have 
very little tendency to bleed. Lachrymation is a common symptom in 
consequence of pressure on the nasal duct. Simple polypus sometimes 
projects into the pharynx, of which Mr. Liston gives the accompanying 
delineation. 

Care must be taken not to mistake for this disease abscess in the 
nostril — projection of the septum to one side — general congestion of the 
mucous membrane — or hypertrophy of the inferior spongy bone. In 
every instance the nostril should be carefully explored by means of the 
speculum, a drawing of which is here given. 

Fie. 270. 




Valuable information will thus be obtained in doubtful cases as to the 
nature, form, and situation of the polypus ; and also, after operation, 
as to whether or not the disease has been completely removed. 




Treatment. — As a general rule it may be stated, that the best treat- 
ment is evulsion by means of a forceps. The blades should be applied 
to the neck of the polypus, which should be firmly grasped between 
them, and then by a gentle turn of the hand the polypus is separated 
and extracted. 

Separation is effected not by pulling, but by twisting in one direction ; 
in short, by one turn or twist of the hand. Care must be taken that it 
is the polypus only, that is between the blades of the forceps ; and all 
violent efforts must be avoided, lest either the membrane or bones 
should be injured or detached. If hemorrhage should continue after 
some minutes, the nostril should be slightly plugged for a short time by 
introducing a long piece of lint by means of a blunt probe. The lint 
should, however, be withdrawn as soon as the tendency to oozing has 
ceased. Except in the very rare case of a single polypus, several ope- 
rations are required before the nostril is perfectly cleared of the disease. 
This should be made known to the patient before the first operation, 
when extraction should be carried to such an extent, as to enable the 
patient to breathe freely through the nostril. Subsequent operations 
should take place in eight or ten days, that is, when the irritation of the 
previous one has worn off. After one or more of these operations, there 
sometimes appears to be a return of the polypi. Strictly speaking, 

Fig. 270. From Liston. 



714 AFFECTIONS OF THE NOSE. 

however, this is not a reproduction of those which have been extracted, 
but the coming into view of some which had been confined in anfractu- 
osities and narrow parts of the nostril, or the growth of others which 
had previously been kept pressed down, but which the removal of the 
cause of compression has left free to grow. When it is believed that 
the nostril is perfectly cleared, the tendency to return should be com- 
batted, and a healthy condition of the lining membrane promoted by 
gently touching the part with nitrate of silver, and by the use of astrin- 
gent lotions. When polypi are attached to the mucous membrane 
covering the inferior turbinated bones — which is very rarely the case, 
except in children — extraction is very safely effected by cutting the 
neck of the polypus with a pair of narrow probe-pointed scissors, while 
its base is held, and then brought out by means of a spring-forceps. In 
adults, also, these instruments are in some cases convenient for accom- 
plishing extraction ; but as a general rule, evulsion by the forceps is to 
be preferred. 

CYSTO-MUCOUS POLYPUS. 

This variety of polypus agrees so much with the former in form, in 
situation, in its attachment not extending deeper than the mucous 
membrane, in symptoms, in the mode and result of treatment, and in 
many other particulars, that it is only necessary to remark, that the 
colour is paler, that it does not present a uniform structure, but con- 
sists of various cysts filled with a mucous fluid, and that the parietes of 
the cysts are much more dense than the substance of simple polypus. 

FIBROUS POLYPUS. 

The peculiarities of this form of polypus were first pointed out by the 
celebrated M. Dupuytren, who gave it as his opinion that the fibrous 
polypus often degenerates into the medullary. This opinion has been 
also held by many other observers ; but Professor Syme, whose expe- 
rience in this department has been large, doubts its correctness, on 
the ground that medullary tumours in this situation exhibit their dis- 
tinctive characters at a very early period, and that he has seen fibrous 
polypi retain their distinguishing peculiarities after they had been of 
long standing and had attained a great size. 

The pain is severe ; the texture of the polypus is firm, like that of 
fibrous tumour, of which this variety of polypus of the nose is a good 
example. It is most common in males between the adult and middle 
periods of life ; it is pyriform, pendulous, hanging down into the 
throat ; and is remarkable for its tendency to bleed, for. the great size 
it attains ; and for its attachment being to the periosteum, and not to 
the mucous membrane alone. Another point in which this variety 
differs from the former is, that the polypus is single. If not removed, 
it may prove fatal by hemorrhage, suffocation, or pressure on the brain. 
The principal peculiarities may be stated briefly to be, — attachment to 
the periosteum, rapidity of growth, great size, being single, great ten- 
dency to bleed, separation of the bones of the nose, and a much more 
aggravated character of all the symptoms than in the two previous 
varieties. 



AFFECTIONS OF THE NOSE. 



715 



Treatment. — In this variety, the polypus very frequently hangs down 
into the throat. One mode of proceeding is, to seize the roots with the 
forceps, detach it from the periosteum, and press the polypus back into 
the throat. In this way the disease has in very many instances been 
completely removed. Another mode of proceeding very generally 
applicable to such cases is, to pass through the nostril into the pharynx, 
a double of silver wire, catgut, or whipcord, which last Mr. Liston re- 
commends^ — to guide the double around the body of the polypus by the 
fore and middle fingers, — and then to draw the ends ; this will send the 
double up around the neck of the polypus which is to be strangled by 
bringing the ends through a double canula, and fixing them tightly at 
its extremity. 

Fig. 272. 




From the accompanying wood-engraving, taken from Mr. Liston's 
" Practical Surgery," this proceeding will be clearly understood. 



MEDULLARY POLYPUS. 



Medullary, bleeding, and malignant, are the titles given to this per- 
fectly incurable form of polypus. The principal distinctive characters 
are, that it usually occurs at the middle and later periods of life ; that 
it commences in the bones of the nasal parietes : that its growth is in 
general rapid ; that it is attended with great pain ; attains a great size ; 
and causes a separation of the bones of the nose, and in consequence, a 
very unpleasant expression of countenance ; that it has a great tendency 
to bleed ; and emits a very offensive bloody discharge ; that it is always 
soft — so much so, that the forceps will often take away only the 
portion between its blades ; and that, in addition to the usual symp- 
toms of polypus in an extremely aggravated degree, the patient ere 
long exhibits the usual signs of malignant cachexy. In this, as in other 
malignant diseases, the only relief the surgeon can give, is to palliate the 



Fig. 272. From Liston. 



716 



AFFECTIONS OF THE NOSE. 



most urgent symptoms ; and with regard to local interference, there can 
be no doubt that it is exceedingly desirable, if possible, to avoid it al- 
together, as patients are likely to live longer if nothing be done. 
Sometimes, however, to prevent suffocation, portions of these tumours 
are cleared away ; but cases not unfrequently occur, in which the least 
interference causes so much hemorrhage and irritation, that even this 
proceeding, for the relief of an extremely urgent symptom, cannot be 
resorted to without great danger. The language of one of the greatest 
surgical authorities in regard to these tumours in the nose, is, " Such, 
growths, when they present in the nostrils, are perfectly irremediable 
and uncontrollable by any surgical proceeding." 

OPERATION OF PLUGGING THE POSTERIOR NOSTRIL. 

The principal remedies for arresting spontaneous epistaxis are, per- 
fect quiet, abstraction of stimuli, and the internal use of gallic acid, 
elevation of the head, local application of styptics, compression of the 
nostrils, and the methodical introduction of lint through the anterior 
opening of the nasal fossa. It is very seldom that the last-mentioned 
proceeding has not the desired effect ; but when the above remedies are 
not successful, it is necessary to plug the posterior nostril. This may 
be readily accomplished by sending a piece of silver or other wire., or of 
catgut, with a ligature fixed to it, along the floor of the nostril, into the 

Fig. 273. 




throat ; bringing one end of the ligature through the mouth, by taking 
hold of it with a forceps when seen in the throat, and the other through 
the nostril, by drawing out the wire. The most convenient mode of 
introducing the ligature, however, from the nose to the throat, and for 
bringing back one end through the nostril, is the exceedingly suitable 
instrument contrived for the purpose. 

To the portion of ligature coming through the mouth, a bit of lint 
proportioned to the size of the posterior nostril is attached, and by draw- 
ing the nasal extremity of the ligature, and guiding the plug behind the 

Fig. 273. From Liston. 



RHINO PLASTICS. 



717 



velum pendulum palati, it can be lodged in the posterior nostril. This 
being done, the anterior nostril should be methodically filled with a 
long narrow bit of lint, when the hemorrhage will be completely com- 
manded. 



RHINOPLASTICS. 

Restoration of the whole nose is now performed as follows : The cica- 
trized remains of the old nose having been pared down to a considerable 
depth, so that the edges and the whole surface are made raw — to which 
a flap borrowed from the forehead is to be applied — a piece of soft 
leather, shaped of the size required to form the apex and alse, is placed 
on the forehead, with the narrow part between the eyebrows, and the 
broad part upwards. The outline of the flap having been marked with 
ink or with a knife, the flap is dissected down, care being taken to make 
it of uniform depth, and not to interfere with the pericranium. The 
neck of the flap should be made sufficiently long to admit of its being 
turned round without injury to 

the circulation, and to facili- Fig.«274. 

tate this turning round, it is 
advisable to make the incision 
a little longer on the side to 
which the twist is to be made. 
Bleeding having ceased, the 
flap should be turned round, 
and its edges, after being care- 
fully adjusted to the margins 
of the remains of the former 
organ, secured by sutures ; a 
little oiled lint is placed in the 
nostrils to support the flap, 
and no further dressings are 
applied to the part. The 
edges of the wound in the 
forehead at its lower part are 
brought together by a suture, 
and the remaining part treated 
with tepid-water dressings to 
promote granulation. 

The organ having become consolidated, restoration of the columna 
may be accomplished by the following operation, recommended by Mr. 
Liston, and practised by him with great success. 

" The inner surface of the apex is first pared. A sharp-pointed bistoury 
is then passed through the upper lip, previously stretched and raised by an 
assistant, close to the ruins of the former columna, and about an eighth of 
an inch on one side of the mesial line. The incision is continued down, in a 
straight direction, .to the margin of the lip ; and a similar one parallel to the 
former, is made on the opposite side of the mesial line, so as to insulate a 
flap composed of skin, mucous membrane, and interposed substance, about 




Fi;r. 274. From Liston. 



718 RHINOPLASTICS. 

a quarter of an inch in breadth. The frsenulum is then divided, and the 
prolabium of the flap removed. In order to fix the new columna firmly 
and with accuracy in its proper place, a sewing-needle — its head being 
covered with sealing-wax to facilitate its introduction — is passed from 
without through the apex of the nose, and obliquely through the extre- 
mity of the elevated flap: a few turns of thread sufiice to approximate 
and retain the surfaces. It is to be observed that the flap is not twisted 
round as in the operation already detailed, but simply elevated, so as to 
do away with the risk of failure. Twisting is here unnecessary, for the 
mucous lining of the lip, forming the outer surface of the columna, rea- 
dily assumes the colour and appearance of integument, after exposure 
for some time, as is well known. The fixing of the columna being ac- 
complished, the edges of the lip must be neatly brought together by the 
twisted suture. Two needles will be found sufficient, one being passed 
close to the edge of the lip ; and they should be introduced deeply 
through its substance ; two-thirds at least of its thickness must be super- 
ficial to them. Should troublesome bleeding take place from the coro- 
nary artery, a needle is to be passed so as to transfix its extremities. 
The whole cut surface is thus approximated ; the vessels being compressed, 
bleeding is prevented ; and firm union of the whole wound is secured. 
The ligature of silk or linen, which is twisted round the needles, should 
be pretty thick and waxed ; and care must be taken that it is applied 
smoothly. After some turns are made round the lower needle, the ends 
should be secured by a double knot ; a second thread is then to be used 
for the other needle, and also secured. With a view of compressing 
and coaptating the edges of the interposed part of the wound, the thread 
may be carried from one needle to the other, and twisted round them 
several times ; but in doing this, care must be taken not to pull them 
towards each other, else the object of their application will be frustrated, 
and the wound rendered puckered and unequal. Last of all, the points 
of the needles are to be cut off with pliers. No further dressing is re- 
quired. As previously remarked, no good end can be answered by any 
application, and the separation of dressing may afterwards be trouble- 
some ; discharges from the neighbouring passages are retained by it, 
foetor is produced and union interrupted. The needles may be removed 
on the third day ; their ends are cleaned of coagulated blood, and, after 
being turned gently round on their axis, they are to be cautiously with- 
drawn, without disturbing the thread or the crust which has been formed 
about them by the serous and bloody discharge. This often remains 
attached for some days after removal of the needles, and forms a good 
protection and bond of union to the tender parts. Some care is after- 
wards required from the surgeon and patient in raising the alae, by filling 
them with lint, and thus compressing the pillar so as to diminish the 
oedematous swelling which takes place to a greater or less degree in it, 
and to repress the granulations. It is besides necessary to push upwards 
the lower part of the column, so that it may come into its proper situ- 
ation ; and this is done by the application of a small round roll of 
linen, supported by a narrow bandage passed over it and secured behind 
the vertex. 

" Independently of the great improvement produced on the patient's 



AFFECTIONS OF THE ANTRUM. 719 

appearance by the restoration of the lost part of so important a feature, 
it may be observed, that, when the columna has been destroyed, the lip 
falls down, is elongated, and becomes tumid, particularly at its middle, 
so that borrowing a portion from it materially ameliorates the condition 
of the part ; and the cicatrix being in the situation of the natural fossa, 
is scarcely observable." 

AFFECTIONS OF THE ANTRUM. 

The antrum is not unfrequently the seat of collections of matter of 
various kinds, and sometimes of polypi. It is not unfrequently occu- 
pied with a fluid of a clear and glairy appearance. Some remarkable 
examples of this class are recorded, and two have come under my own 
observation. In cases of this nature the fluid is sometimes slightly puri- 
form, and very often resembles in appearance the fluid found in cysts in 
other parts of the body. The walls of the cavity become expanded, 
attenuated, and in some cases so thin as to crackle on pressure. Col- 
lections of this nature are not attended with symptoms of the inflam- 
matory process. 

The antrum is also subject to acute and chronic abscess ; but the 
former rarely occurs, except in consequence of violence applied to the 
bone, or of very acute disease in the teeth or gums. In all such instances 
the grand indication is, to make early, free, and dependent opening for 
affording complete evacuation and preventing reaccumulation. If the 
canine or one of the molar teeth be diseased, it should be extracted ; the 
matter often escapes through the empty socket, and it is a frequent 
practice to enlarge this communication by sending a trocar through the 
empty socket into the antrum ; but the more effectual mode of procuring 
evacuation and preventing reaccumulation is, to make an early free 
opening by dividing the membrane of the cheek and the attenuated 
parietes immediately above the molar teeth. 

The antrum is very rarely the seat of any kind of polypus, except 
the malignant, which is, of course, as irremediable here as it is in the 
nostril. It is of great consequence not to confound this affection or 
osteocephaloma of the jaw with osteosarcoma ; the former being cer- 
tain to prove fatal, and the latter as certain to be cured by excision of 
the upper jaw, — an operation described in the chapter on resections of 
bone. 



720 



CHAPTER XXIII. 

AFFECTIONS OF THE MOUTH, THROAT, AND WINDPIPE. 

AFFECTIONS OF THE MOUTH. 
CANCER OF THE LIP. 

This disease is almost entirely confined to the under lip. I have 
never seen it in the upper lip as a primary affection, and very rarely, 
indeed, as an extension from the lower ; and it is well known that such 
extension seldom takes place. The greater liability of the lower lip to 
this disease is supposed to arise from its being much more exposed to 
irritation on account of its situation and mobility. This affection is 
more frequent in males than in females, and like all others of the same 
class, is more common after than before the middle period of life. Very 
lately, however, in the Royal Infirmary, I removed a scirrhous tumour 
from the lip of a female under twenty years of age. In that case the 
common and microscopic characters of carcinoma were exceedingly dis- 
tinct. 

The disease may originate in a carcinomatous tumour in the lip, over 
which the skin or mucous membrane at last ulcerates, so that a Cance- 



ls T) 

■:■.■/ 

x 



■$' 









C:^iAMvt ; n,#^ ^W'^M^^il 




rous sore is constituted ; or in a warty excrescence, which degenerates 
into cancerous ulceration ;. or in a superficial chap, ulcer, or excoriation. 
The form of the disease is the scirrhous variety. 

There is an affection, however, very common in the lip which differs 
from cancer, and is considered an epithelial formation, consisting prin- 
cipally of hypertrophy of some of the natural tissues of the lip. A 

Fig. 275. Appearance of section of cancerous tumour of the cheek, a. Epidermic 
scales and fusiform corpuscles on the external surface, b. Group of epidermic scales. 
c. Fibro-elastic tissue of the dermis, d. Cancer cells infiltrated into the fibrous tissue, 
and filling up the loculi of dermis. — (From Bennett.) 



AFFECTIONS OF THE MOUTH. 721 

respected authority gives as the result of numerous microscopical obser- 
vations on this subject the following remarks : — 

" The papillae of the cutis were hypertrophic, and very considerably 
lengthened. Whilst upon the whole surface of the papilla? a plaster of 
epithelial cells had been formed, which continually grew, and were 
thrown off as scales ; so was each papilla surrounded at its extremity 
with a thick sheath of epidermis, and thus a cylinder was formed into 
which the base of the papilla, often capable of being drawn like a thread 
out of its sheath, entered. These cylinders, at first close to each other, 
were pushed apart by the scaling, though still held together on the sur- 
face by a layer of epidermal scales. In many cases the epithelial for- 
mation was very great, and presented an appearance nearly allied to 
warts and condylomata." 

Such is the description given by Earle of this disease, which he has 
described as hypertrophy of some of the natural tissues of the lip. 
This is the disease described by Professor Bennett in his valuable work 
on " Cancerous and Cancroid Growths," under the name of Epithelial 
Growths, which he refers to the class of cancroid growths, using that 
expression in the sense affixed to it by Lebert, namely, to denote those 
tumours which more or less resemble cancerous tumours, and are con- 
stantly mistaken for them, but do not correspond with them in struc- 
ture ; and limiting the term cancerous to those growths which exhibit 
the characteristic peculiarities of that disease. Professor Bennett re- 
marks, " These growths generally commence by an induration or wart 
upon the skin or mucous surface. In the former position they are ge- 
nerally harder than in the second. Sometimes they constitute cauli- 
flower excrescences or condylomata, made up of elongated papillae, ag- 
gregated together, with their summits more or less flattened. In this 
condition their diagnosis is generally easy. At other times, sooner or later 
after their formation, they soften externally, and become covered with 
crusts of inspissated pus and epithelium. This, on separation, becomes 
an ulcerated surface, presenting irregular clefts or depressions between 
the hypertrophied papillae, the edge is everted, and the base and margins 
gently indurated. The ulcer may slowly spread over a considerable 
portion of the surface, and cause great swelling of the lymphatic glands 
from the irritation produced. In this condition such ulcers are usually 
considered to be cancerous. The progress of an ulcer, commencing ex- 
ternally in warty excrescences spreading laterally, slowly, and proceed- 
ing from without inwards, is directly opposite to the progress of cancer, 
which almost invariably commences deep-seated, produces ulceration se- 
condarily by thinning of the integument, and throws out subsequently 
and rapidly fungoid masses. Hence the progress of the case is often 
diagnostic. This, conjoined with the microscopic examination of the 
projecting papillae, and the absence of cancer cells, will in most 
cases sufficiently establish the nature of the disease." For much inte- 
resting information regarding epithelial cancroid growths, the reader is 
referred to Professor Bennett's admirable treatise on " Cancerous and 
Cancroid Growths." 

The lip is liable to various ulcerations of a simple, syphilitic, or other 
nature, which prove obstinate from the constant motion of the part, 

46 




722 AFFECTIONS OF THE MOUTH. 

and the irritation caused by the fluids of the mouth. These may gene- 
rally be distinguished from cancer of the lip, 
Fig. 276. by the absence of the characteristic peculiarities 

of cancerous ulceration, the history of the case, 
and their usually being amenable to proper 
general and local treatment. The microscope, 
moreover, will afford conclusive evidence whether 
the tumour be cancerous or not, if a minute 
portion be removed and examined under it. 

Treatment. — The proper proceeding is the 
entire removal of the mass by excision at the 
earliest possible period. When the disease is 
confined to a moderately narrow space, the 
lip is seized by the forefinger and thumb of 
^^^^uuiiiiiiiw^^ the left hand, and drawn out from the gum. 

Two straight converging incisions are then 
made downwards with a sharp bistoury so as to meet in a point 
below, including the whole diseased part along with a small border of 
sound tissue in the triangular or V-shaped piece, which is thus removed. 
I generally perform the excision with a single stroke, employing for 
that purpose a very narrow straight bistoury, which being carried down 
one side admits of being rapidly turned at an acute angle, after which it 
is brought up on the other aspect of the tumour. By this method 
excision can be very rapidly accomplished, and, by using a very narrow 
knife, the angle at the bottom of the wound can be made as sharp as 
by the usual methods of making two distinct incisions both carried 
downwards, or of making one incision by transfixing, and the other by 
cutting downwards. Before the operation is commenced, the angles of 
the mouth may be compressed so as to prevent the flowing of blood 
from the coronary arteries during its progress ; or the same purpose 
may be effected by pressing on the facial artery, on each side as it runs 
on the groove at the union of the middle with the posterior third of the 
base of the inferior maxilla. 

The wound is treated afterwards as in cases of hare-lip, and the ne- 
cessity of tying bleeding vessels is obviated by making the needles of 
the twisted suture transfix those points from which blood would other- 
wise flow in any quantity. When the disease affects the greater part or 
the whole of the breadth of the lip, it may be removed in a slice by a 
crescent-shaped sweep of the knife ; after which the margins of the skin 
and mucous membrane may be approximated and kept together by the 
smallest form of the little spring forceps mentioned in the chapter on 
Wounds as being employed for such a purpose in Paris. In the absence 
of this little instrument, one or two points of the interrupted suture may 
be employed, but much less advantageously. The crescent-shaped 
slicing of the lip is best adapted for those cases in which a considerable 
breadth, but only a small depth, of the lip is implicated. When the 
disease extends far down as well as laterally, the triangular excision 
should be practised, and the operation completed by Professor Syme's 
proceeding for the restoration of the lower lip. 

Fig. 276. From Liston. 



AFFECTIONS OF THE MOUTH. 723 



HARE-LIP. 

Hare-lip is the name applied to the condition in which one or more 
fissures exist in the upper lip. It is usually congenital, and caused by 
arrest of development ; but it may be induced accidentally by wounds. 
The fissure, when single, is usually in the central line, though sometimes 
it is situated a little towards one side : when there are two fissures, they 
are generally placed below the apertures of the nostrils ; and in this 
case the central portion of the lip may be either of the full length, or, 
as is more usual, merely a short rounded process. A mesial portion of 
the superior maxillary bones frequently projects forwards, more espe- 
cially in double hare-lip. Cleft palate is a frequent accompaniment of 
this condition. 

Hare-lip, when very slightly marked, may not much impede the child's 
sucking ; but when it is to a greater extent, it may very much interfere 
with it — nay, even render it impossible. 

The best time for an operation for the removal of this deformity is, 
when most of the temporary teeth have come through the gums : this 
is the time usually preferred by the surgeon, when 
it rests with himself to decide ; but when parents are • Fi S- 277 - 
unwilling to have the operation delayed, he performs 
it before the commencement of dentition. It has, 
however, been done with perfect success, and without 
any unpleasant results, at all ages, from two months 
upwards ; but it is not desirable, and certainly it is 
not necessary to operate earlier than three or four 
months after birth, as the operation can be well 
done at a later period, and no bad consequences 
are caused by delay. 

When a simple fissure exists without malformation of the upper max- 
illa, it may be rectified in the following manner : 

A towel, or large cloth, having been wrapped round the child, so as 
completely to secure its hands and feet, and prevent all struggling, it is 
placed on the nurse's knee with the head secured between the surgeon's 
knees. He then seizes the lower corner of one side of the fissure, be- 
tween the finger and thumb, and sends a sharp, narrow, straight-bladed 
bistoury through the lip, immediately above the apex of the hiatus, with 
its edge directed straight downwards ; the blade is then slightly turned 
so as to direct the edge a little outwards, and is brought down, cutting 
off a thin slice from the edge of the fissure. The opposite corner of 
the lip is next seized, the bistoury is introduced at the same point, and 
is made to cut off a similar slice from the other side. In a central fis- 
sure these two incisions, though smooth and uniform, should not be ex- 
actly straight ; they should, as Professor Syme recommends, be very 
slightly curved with the convexity directed outwards, so that, when the 
margins are approximated, the natural fulness of the prolabium at this 
point may be preserved. Without this little precaution there usually 
remains a notch in the lip, which is unseemly, however small. 

Fig. 277. From Liston. 




724 



AFFECTIONS OF THE MOUTH. 



Fig. 278. 



Approximation of the clean cut edges having been effected, one or 
two common sewing needles of suitable size, and provided with a knob 
of sealing-wax on the head to serve as a handle, or needles with spear 
points, or pins with spear points, both of which are made expressly for 

this operation, are introduced so as to trans- 
fix both margins, passing through about 
two-thirds of the thickness of the lip, but 
not penetrating the mucous membrane. 
Their points are broken off with a forceps, 
and a waxed ligature is then twisted in the 
form of the figure 8 around their extremi- 
ties, which emerge from the integument at 
a little distance from the margins of the 
wound on each side. Each needle is sup- 
plied with a separate ligature ; because if 
the same thread be continued from one 
needle to the other, puckering of the wound 
between the two is apt to be produced. 
No dressing whatever should be applied 
over the wound. 
In this operation it is of great importance to have the edges evenly 
and uniformly cut, meeting at a sharp angle above, so as to facilitate 
accuracy of coaptation. The sharpness of the bistoury, and its being 
narrow-bladed, will contribute much to the accomplishment of both these 
ends. One of the needles may be removed in two or three days, by 
gently twirling it round as it is withdrawn, the wax thread rendering 
this manipulation easy : the other may be taken away two days after- 
wards, or in many cases even sooner ; but the twisted threads which 
have been soaked in the oozed blood, and in drying have become strongly 
adherent, may be left undisturbed for several days longer. 

A double fissure, without malformation of the upper jaw, is treated 
on similar principles. The lip, if tightly adherent to the gum, is 




Fig. 27! 



Fig. 280. 





~ 5! Si4Wttft^ 



loosened sufficiently by cutting the mucous membrane. Then, if the 
central lobe between the two fissures be of full breadth and length 
down to the prolabium, the margins of both fissures are pared, forming 
two complete and separate lines of wound ; but if the central portion 



Figs 278, 279, 280. From Liston. 



AFFECTIONS OF THE MOUTH. 725 

be short and rounded, it is sliced so as to bring it to a point at the bot- 
tom, as is represented in the accompanying wood engraving, and the 
margins on each side being also pared, are brought together, embracing 
this little part above, but coming into contact with each other below. 
In both cases the same needles serve for both slits, being made to 
transfix the central piece without appearing on its surface, and emerging 
on the skin a little beyond the outer edge of each fissure. The threads 
are wound around as before. In all cases it is preferable to operate on 
both sides at once, and not to make two operations at different periods. 
When there is malformation of the upper jaw, so that it projects 
slightly in the centre, the case may be treated without any peculiarity 
of proceeding ; for the steady yet gentle pressure of the united lip, as I 
have often seen in cases coming under my own observation, gradually 
depresses the prominent piece of bone, at least in young children. But 
if it project so much as to prevent the possible closing of the fissure over 
it, it may generally be pressed back by a suitably contrived spring pad, 
which is kept applied with a gentle degree of pressure for a few hours 
daily during some weeks, after which the operation may be performed. 
This is preferable to snipping off the piece of bone with the forceps, a 
proceeding very rarely indeed necessary in these cases. When any 
teeth project very much forward, they should be extracted previous to 
the operation, as the irritation caused by them would be apt to prevent 
adhesion. In order to prevent the needles from keeping up a strain 
and tension of parts in cases where the fissures are very wide, which 
might lead to their being set free by ulceration, and thus produce return 
of hare-lip, several varieties of apparatus have been employed to press 
the cheeks forwards towards the mesial line. The best for this purpose 
is the apparatus employed by Mr. Fergusson, and described in a late 
number of the " Medical Times ;" it consists of a spring, forming the 
greater part of a circle, with a soft pad affixed to each extremity, and a 
strap to prevent the apparatus from falling too far down ; the pads 
being directed forwards, and intended to press in the cheeks and prevent 
their retraction, after they have been drawn forwards by the fingers of 
an assistant. By using this apparatus, and by attending to a most im- 
portant point, namely, the free division of the mucous membrane when 
necessary, so as to liberate the soft parts from the bone, and admit of 
their being brought forward, the worst possible deformity of this nature 
is capable of being perfectly cured. 

RESTORATION OF LIP. 

Restoration of a lip is an operation occasionally demanded ; in some 
cases merely to prevent deformity, in others to remove more serious in- 
conveniences, such as imperfect articulation, and a constant flow of saliva 
outwards. 

The upper lip is but little subject to disease, though exceedingly 
liable to congenital fissures. These, however, are usually so narrow 
that their sides can be approximated without difficulty. But if the 
operation for hare-lip be performed several times on the same individual, 
and as often fail, the repeated paring of the edges, and the ulceration 
which sets the needles free, destroy the lip to such an extent that it may 



726 FISSURE OF THE PALATE. 

be impossible again to bring the parts together without incurring one or 
other of the following consequences, — either the commissures of the 
mouth will be dragged inwards so as nearly to meet under the columna 
of the nose ; or, if the apposition be partially effected at the upper 
angle of the fissure, the free border of the lip thus left will be composed 
of the irregular margins which ought to have formed a direct continua- 
tion of the vertical junction above, and not a line obliquely transverse 
to it ; and its rounded corners, at the point of union in the centre, will 
leave a retiring- angle, sufficient still to afford to the lip a decidedly 
leporine appearance. 

When the upper lip has been destroyed in this manner, Mr. Syme 
restores it by the following method. After paring evenly the edges of 
the gap, which resemble the limbs of the capital A set very widely, or 
at an obtuse angle, he makes an incision about an inch and a quarter 
long, or about the same length as the pared border, across each cheek, 
outwards and a little upwards, in the direction of the zygoma. These 
four incisions resemble a widely-printed W. The margins of the central 
gap can now be readily approximated, and secured in the - usual way 
by the twisted sutures. A stitch of the interrupted suture may be 
required at the outer part of the lateral incisions, the upper margins 
of which, being drawn inwards, chiefly form the prolabium, while the 
natural elasticity of the integument prevents the injurious straining of 
this edge, or the rough corrugation of the lower border. 

The lower lip, much more frequently than the upper, requires to have 
a large portion removed, when the intractable or malignant affections, 
to which it is so liable, have been allowed to pursue their course for a 
considerable period. Here the gap is generally of more formidable di- 
mensions, and is more inconvenient than even an extensive fissure of 
the upper lip, as there is in this case greater difficulty in restraining the 
outward flow of saliva. 

Professor Syme has successfully restored the deficiency by the fol- 
lowing operation. 

A triangular excision of the diseased mass having been made, two 
straight incisions are carried from its apex downwards and outwards 
nearly in a continuous line with the cut margins of the V-shaped hiatus, 
forming thus far the letter X. Each of these lower cuts is finished off 
by being continued outwards for a short distance in a curve, the con- 
vexity of which is directed downwards, and its free extremity turned 
upwards. The flaps thus formed are detached from their underlying 
connexions, as far outwards as the extremities of the gaps above, and of 
the curved prolongation of the downward incisions below. The oblique- 
ly-placed V margins, from which the diseased tissue has been cut, can 
now be made horizontal by raising their inferior internal angles, forming 
thus the free border of the new lip ; the outer edges of the straight 
parts of the incisions, which were carried obliquely downwards and out- 
wards, become by the same movement vertical, and are brought into 
mutual apposition ; and the curved portions immediately below and out- 
side accommodate themselves along the sides of the triangular tongue 
of integument, from contact with which the straight margins of the in- 
cisions have just been elevated. The elasticity of the skin prevents any 



FISSURE OF THE PALATE. 727 

undue straining or unseemly corrugation, which might otherwise have 
occurred in the adjustment of these curved lower parts of each in- 
cision. 

The twisted suture is employed to retain in coaptation the vertical 
line of union thus effected, from the border of the lip down to the point 
where the two lateral parts of the wound branch off. The lower of the 
three or four needles required for this purpose should also transfix the 
apex of undetached skin which occurs at this last point. About the 
same number of stitches of the interrupted suture are then inserted, to 
connect the edges of each of the two diverging incisions below. 

Professor Serre of Montpellier has suggested and practised a method 
of forming a new lower lip, presenting the advantage of being lined by 
a mucous membrane. This consists in making two incisions, one from 
each end of the lip downwards, which meet in the mesial line a little 
above the pomum Adami. Other two incisions are then made horizon- 
tally from the angle of the mouth to the borders of the masseter muscles 
in a line with the teeth of the upper jaw, and below the level of the 
parotid duct. These two latter incisions extend 'through the whole 
thickness of the cheeks. The flaps included between the incisions on 
each side are then carefully separated from the subjacent parts, and the 
margins brought together and retained by hare-lip pins and twisted su- 
tures. The integument and mucous membrane are then also brought toge- 
ther at the edge of the new lip by means of a few simple sutures. In the 
"Medical Times," for January 3d, 1852, an account will be found of 
a case in which Mr. Lawrence performed this operation in St. Bar- 
tholomew's Hospital ; the only instance, so far as I know, in which 
Professor Serre's operation has as yet been performed in this country. 

FISSURE OF THE PALATE. 

Congenital Fissure affects sometimes the uvula merely ; sometimes the 
whole velum palati, the hard palate being entire ; sometimes the bones 
alone, the velum being entire ; sometimes the velum palati and bones, 
as far forward as the alveolar process, in which case the fissure^is inva- 
riably in the mesial plane ; and sometimes the velum palati, the hard 
palate, and alveolar arch, — a case in which the fissure, if single in front, 
diverges a little to one side, where it goes through the arch, but if 
double, the state of the palate resembles the outline of the letter Y; 
sometimes, also, the fissure of the whole palate is combined with hare- 

h p- . ... 

Extensive fissure causes great difficulty in sucking, as the food in 
being swallowed passes through the nostrils ; it also causes great impe- 
diment in articulation, rendering it exceedingly indistinct and disagree- 
able. 

When fissure of the palate is combined with hare-lip, the first proceed- 
ing should be to remove the latter deformity ; this having been effected, 
the velum palati, if the fissure be not of very great breadth, should be 
made the subject of operation ; after which the hard palate should be 
covered by a plate. For fissure of the hard palate alone, the patient 
must wear a plate properly prepared and fitted by a dentist : and for 
fissure of the soft palate, the operation of staphyloraphy, or velo-syn- 
thesis, is resorted to ; an operation practised by Roux, Graefe, and 



728 FISSURE OF THE PALATE. 

others, but brought to its present greatly improved state by Professor 
Fergusson of King's College Hospital, who may be said to have proposed 
a new mode of Staphyloraphy, the principle of which is, to divide the 
muscles that draw the flaps from each other and widen the fissure ; by 
this means the velum is put into a state of repose, and the pared edges 
are in less danger of being pulled asunder during the process of union. 
Professor Fergusson commences operative proceeding by dividing the 
levator palati and palato-pharyngeus muscles, and in some cases the 
palato-glossus. , 

To give the reader a complete account of this interesting operation, 
and also of the considerations which suggested this new and very useful 
proceeding to the Professor's mind, I think it advisable to give his own 
remarks, as they appeared in the " Medical Times," for March 6th and 
March 13th, 1847. 

" It had long been familiar to those accustomed to see such cases in 
the living body, that during deglutition the two portions of the uvula 
came together in the middle line ; but no one had attempted to explain 
how this could happen, and even such an acute observer as M. Malgaigne 
stated, that it was ' by a muscular action, of Which it is difficult to give 
an explanation.' The dissection of the parts enabled me to explain this 
in a- way which I imagine is incontrovertible ; and to show you how this 
happened, as well as for other purposes, it will now be best that I should 
explain to you the condition of the parts in this malformation, and con- 
trast it in as far as may be requisite with the natural state. 

" The preparation now before you exhibits the upper part of the mouth 
and pharynx of an aged female subject. The muscles of the pharynx 
have been carefully dissected, as have also those connected specially 
with the palate. A glance at the roof of the mouth shows the gap in 
the mesial line, and how the uvula, soft palate, and a portion of the 
hard, are involved in the defect. Behind it may be observed that the 
constrictors are not so broad, so capacious, as in the natural condition, 
but that the muscular fibres are nevertheless as strongly developed. 
The uro^er border of the superior constrictor is especially well marked, 
and here it may be seen to form a kind of semicircular margin, extend- 
ing between the basilar process of the occipital bone and the internal 
pterygoid plate, on which margin the levator palati muscle seems to 
rest. A perpendicular incision has been made through the pharynx be- 
hind, exactly in the mesial line, and, the mucous membrane having been 
stripped off the inside, the muscularity is thus rendered still more dis- 
tinct. The mucous covering has also been taken off the upper surface 
of the palate, whereby one side of the nostril immediately above, and 
the muscles of the palate, have been more extensively exposed. 

" It may now be seen how the two portions of the uvula and correspond- 
ing parts of the soft palate touch each other during deglutition, for it is 
evident that, as the superior constrictor muscles act, they must throw or 
push the soft tissues in front forwards and inwards ; — an effect which 
will be aided by the superior fibres of the middle constrictors, which, 
stretching across as they do from one side to the other, having no at- 
tachment mesially, as is also the case with the lower fibres of the supe- 
rior muscles, must contribute powerfully to the result in question. A 



FISSUEE OF THE PALATE. 729 

remarkable difference may here be observed between this and the nor- 
mal state of the parts : the palato-pharyngei muscles are not attached to 
each other, as in the well-formed palate. These muscles are seen to form 
the principal part of the free margin of the palate along the line of fis- 
sure ; their course is somewhat semicircular from their upper end to their 
lower, the convexity being towards the middle ; and it follows, that, dur- 
ing action, if not opposed in any way, they must pull the parts out- 
wards — an action the reverse of that described by Dzondi, Muller, and 
others, as belonging to the muscles in their natural condition. The leva- 
tor palati is seen throughout its entire course, and the tensor palati may 
also be clearly made out. The levator, it will be perceived, as I imitate its 
action by pulling it, not only acts very efficiently on the movable portion 
of the palate, but its sphere of action, from the muscle being chiefly 
muscular throughout its entire course, is so great that, during rigid con- 
traction, it must forcibly pull the soft parts upwards, backwards, and 
outwards. It is worthy of special observation, that the tensor or cir- 
cumflexus palati has hardly any influence on the velum, for, pull as I 
choose upon it, there is only the slightest movement to be observed at 
the parts where its tendon spreads on the surface of the soft palate. 
Neither in the natural nor in the cleft palate can this muscle have a 
power at all to compare with the levator, which, from its length, position, 
and character generally, is the principal motion of this very mobile part. 
The anterior pillar of the fauces is very slight, and the fibres of the 
palato-glossus are indistinct ; the posterior pillar, however, is distinct 
enough, and formed as in the natural state by the bundle of fibres of the 
palato-pharyngeus. The azygos uvulae is by no means distinct ; a bun- 
dle of fibres, about the size of a crow-quill, may be seen on the lower 
part of each free margin of the soft palate. 

" From such an inspection as this preparation afforded, I was led to 
take those views of the physiology and surgery of the parts, the expla- 
nation of which forms the principal object of this lecture. It required 
no great foresight to perceive, that the movement of each side of the 
palate must depend chiefly upon the action of the levator muscle and 
palato-pharyngeus. The influence of the levator muscle might have 
been calculated on from previous knowledge, but that of the palato- 
pharyngeus could scarcely have been thought of. Both must evidently 
have been the effect of widening the fissure, especially the levator ; and 
the various conditions under which the palate may be seen can be 
explained by reference to these two muscles. When the mouth is looked 
into, and the soft portions of the palate are in a quiescent state, the 
fissure will then appear probably in a medium state. A slight irrita- 
tion, with a probe or point of the finger, will cause a corresponding 
movement — the soft parts will be drawn upwards and outwards, so that 
the gap will be enlarged. If the irritation be increased, the same parts 
will be so acted on that they will almost disappear on the sides of the 
fissure, but even now, if an effort at deglutition be made, the two por- 
tions of the uvula will be forced together, by the action of the superior 
constrictors, as already explained. It seemed to me that under ordi- 
nary circumstances, after the operation for closing the fissure, the 
slightest irritation would be likely to call the levatores and palato- 



730 FISSURE OF THE PALATE. 

pharyngei into action, and so induce that dragging on the stitches with 
which surgeons were so familiar— an influence sufficient, in some 
instances, to cause ulceration in the seat of the threads, or, in others, to 
cause separation of the recently-united parts. I therefore supposed 
i that, if these muscles could be divided before bringing the edges of the 
palate together, the parts would remain so quiet immediately afterwards 
that there would be greater probability of union in the mesial line taking 
place than if the muscles were left entire or untouched. It was not 
long before I had an opportunity of testing the project on the living 
body. The result was so satisfactory that I tried it in another instance 
shortly afterwards, and here the effect was most complete. The two 
cases were appended to my paper on this subject when laid before the 
Royal Medico-Chirurgical Society, and since that date I have operated 
on eight more, making ten in all, in eight of which I have been perfectly 
successful in closing the soft palate. In some of these there has been 
fissure of the hard palate as well, and the parties have been content 
with the remaining comparatively small apertures, or have had them 
closed by obturators. I know of four other instances, where the opera- 
tion, conducted on the plan recommended by me, has been successful, 
and a fifth which failed. During the same period I have known three 
examples of failure by the ordinary method. Thus, out of fifteen cases 
on my plan, there have been three which did not succeed, while all those 
done in accordance with Roux's operation were failures. 

" There are cases of cleft palate with which it would be unreasonable 
to meddle, the gap being so large and the soft tissues so narrow, that 
union could not possibly be anticipated. It has been supposed that 
when the two portions of the uvula are observed to touch each other 
during deglutition, the operation may invariably be undertaken ; but 
the fact is, that in almost all instances these two parts touch at this par- 
ticular time, however large the fissure may be, and it is better to be 
guided in deciding upon the propriety of an operation by the condition 
of the parts otherwise. In most cases where the osseous palate is open, 
there will be less certainty of a favourable result than if the soft velum 
alone were implicated. If it seems that only a small portion of the 
fissure in the soft parts can be closed, it will, perhaps, be best to leave 
the parts alone, and to trust for improvement entirely to an obturator 
or false palate, for it has sometimes been found that when there has 
been union only to a small extent, the condition has interfered with the 
proper adaptation of the apparatus. 

" The operation should seldom be undertaken until the patient has 
reached puberty. Much steadiness and self-command is required on 
his part, both during the operation and afterwards ; and it is hardly to 
be expected that one under this age will have the fortitude to do what 
the surgeon expects of him. I have, in one instance, seen a youth of 
eleven years of age comport himself admirably during the operation ; 
but any time between sixteen and four-and-twenty is that which should 
be preferred. 

" The mode of proceeding which I generally follow may be thus 
described : — the patient should be seated on a firm chair with his face 
to the light ; the surgeon should stand a little in front, on the right 



FISSURE OF THE PALATE. 731 

side, and occasionally behind the patient. In this latter position he 
may see into the mouth by leaning over the face, and use his fingers 
-with more satisfaction and facility than if he were always in front, for 
here he is apt to obstruct the light, and possibly fatigue his hands by 
holding them so long in an elevated position towards the roof of the 
mouth. I make an incision about half an inch in length, a little above 
the free margin on each side of the cleft, whereby the levator palati 
muscle is divided. The knife is sharp at the point, and also at each 
side, so that it may be readily passed through the mucous membrane, 
and carried backwards and forwards to enlarge the wound to the re- 
quisite extent. The point of the blade is entered above the middle 
part of each soft flap, where there is the greatest thickness of tissues, 
and, whilst it is carried deep against the levator muscle, it is moved as 
just directed, and not withdrawn until the power of elevating the part 
seems to be done away with. If, when the knife is withdrawn, there 
should still appear strong muscular action in an upward direction, as 
may be ascertained by irritating the parts, it may be used again, as 
possibly the whole of the muscle may not have bee'n cut across. All 
this can be best done whilst standing at the patient's side. The edges 
of the fissure should now be pared ; the mucous membrane of the mid- 
dle part of each margin should be seized with hook-beaked forceps, and 
transfixed with a narrow, sharp-pointed blade, which should then be run 
backwards and forwards, so as to remove a slip of the membrane 
throughout the whole line of the gap. I have found it most convenient, 
at this stage of the proceeding, to stand before the patient whilst paring 
the left side, and behind him while cutting on the right side ; but if the 
surgeon can hold the different instruments in each hand with equal 
facility, he may stand as he chooses. During the time, and more espe- 
cially after these incisions are made, small pieces of sponge rung out 
of iced water should be applied to clean the. parts from blood and 
mucus ; and the patient may also gargle the throat with cold water. 
The stitches should next be introduced thus : — a needle, set in a handle, 
armed with a portion of stout silk thread, three-quarters of a yard long, 
should be passed through the soft flap about a quarter of an inch from 
the free margin, half an inch or less from the posterior edge of the 
osseous palate, from below upwards, and when the eye appears above or 
in the gap, the thread should be seized and drawn into the mouth with 
a forceps ; while the needle is withdrawn, the end of the ligature (as 
yet double) should be brought out from the mouth to facilitate future 
steps, and also to prevent slipping. The same needle, or another like 
it, armed with a thread of a similar length, but much thinner, should 
be passed in like manner through the other side of the left palate, 
exactly opposite the first puncture, and similar manoeuvres should be 
repeated. By fixing this second thread to the bent end of the first, 
where it is hanging out of the mouth, and then withdrawing it in the 
course through which it has already passed, the thread intended to form 
the stitch will thus be brought through the opposite side of the palate, 
when one end of it (for it has as yet been double) can be drawn out, so 
as to leave both ready for knotting. Two, three, or four more threads, 
as may seem requisite, can be introduced in a similar manner ; and now 



732 ABSCESS OF THE TONSIL. 

all that remains to be done is to draw the edges together and fasten 
the thread. The foremost thread should be first tied in accordance 
•with the ordinary mode of making the interrupted suture ; and the 
others should then be treated in the same order in which they have been 
introduced. Should an additional suture seem requisite in any part of 
the fissure, it may now be introduced by pushing the same needle from 
one side to the other — for now, when the parts are more fixed by the 
sutures, this may readily be accomplished. Before fastening the two 
knots furthest back, the pared edges should be brought together to as- 
certain the influence of the palato-pharyngeus in dragging them asunder. 
If this action seems strong, or if there be difficulty in drawing the parts 
together, the threads should be pulled forwards, whereby the posterior 
pillars of the fauces will be put upon the stretch, when each should be 
cut about half an inch behind the uvula, in an outward direction to the 
extent of a quarter of an inch, and then there will be greater relaxation. 
Long curved scissors with blunt points are such as I use for this part of 
the operation, and the same are good for cutting off the ends of the 
ligatures, which is the last step in the operation. 

"In some instances it may appear best to effect the division of the 
palato-pharyngeus before passing the stitches. If this be desired, the fibres 
can be put on the stretch by drawing the uvula forwards with the beaked 
forceps. It will rarely seem requisite to meddle with the palato-glossus, 
but if its division is thought advisable, the scissors just described will 
be the best instrument to use. A small horizontal wound in front of 
the tonsil, and about midway between the tongue and palate, will suffice. 

" The hook-beaked forceps, and also that for seizing the thread, 
should be a little longer than those in common use ; and the curved 
needle is similar to that often employed for the strangulation of hemor- 
rhoids, nasvi, and such like growths. 

" I have named a stout silk ligature, as I think it preferable to any 
other kind. Sometimes I have used a hempen thread, but it is difficult 
to get the material sufficiently small and strong at the same time. I 
have never used the lead ligature, as recommended by Dieffenbach and 
others, and from my experience of the operation, should not feel in- 
clined to try it. The threads to be used should be well rubbed with 
wax, and it is highly advantageous to have them of different colours, so 
that they may be more readily recognised during the proceedings." 

ABSCESS OF THE TONSIL, AND CHRONIC ENLARGEMENT OF THE TONSILS. 

It is not unfrequently necessary to open an abscess in the tonsil. 
For this purpose some use a lancet enclosed in a sheath ; but I have 
uniformly employed the apparatus used by Professor Fergusson and 
many others, namely, a straight bistoury enveloped in lint to within 
about half an inch of- the point. The important precaution to be 
observed is, to keep the point of the instrument directed backwards and 
not outwards, lest the internal carotid artery should be endangered. 

Chronic enlargement of the tonsil not unfrequently takes place to such 
an extent as to cause narrowing of the isthmus faucium, giving rise to 
difficulty of swallowing and breathing, and indistinct disagreeable arti- 



ABSCESS OF THE TONSIL. 



733 



Fig. 281. 




culation. The disease consists of simple hypertrophy, and when it does 
not yield to proper treatment, the 
judicious proceeding is, to shave off 
the tonsil on a level with the folds 
of the velum. 

The patient being placed opposite 
to a good light, and the tongue de- 
pressed, the surgeon seizes the tonsil 
with a vulsellum, and then applies 
the long narrow blunt-pointed knife 
to the under part of the tonsil, and, 
by a gentle sawing movement, shaves 
it off on a level with the folds of the 
velum. In removing the left ton- 
sil, it will be convenient to hold the 
vulsellum in the left hand, and the 
knife in the right ; and in removing 
the right tonsil, to hold the vulsel- 
lum in the right hand, and the knife 
in the left. I have never seen much 
hemorrhage after this operation, and 
have invariably found it most satis- 
factory in its results. 

For removing a part or the whole of the uvula, a spring forceps or 
vulsellum for seizing, and a pair of curved scissors for cutting, answer as 
well as any instruments that could be desired. 

Laryngotomy and Tracheotomy are terms applied (as their deriva- 
tions indicate) to certain operations by which an artificial opening is 
made into the larynx and trachea respectively, for the purpose of ad- 
mitting sufficient air to the lungs, when the natural entrance is closed 
or obstructed by disease, tumefaction, spasm, or impaction of foreign 
matter, so as to threaten death before the obstruction can be relieved 
by other measures, and for the purpose also of removing foreign bodies 
from the larynx, trachea, or bronchi. Both these operations are fre- 
quently referred to under the general name of Bronchotomy, which 
implies cutting the windpipe, without specifying any particular situation. 

Foreign bodies of various forms occasionally enter the windpipe 
during inspiration, and more especially when this act is performed si- 
multaneously with that of deglutition. These bodies are sometimes ex- 
pelled by the convulsive coughing excited by their presence in the air- 
passages, after having remained, in some instances, for weeks, months, 
or even years ; but in most of these cases, serious organic lesions of the 
lungs are induced by the long-continued irritation and inflammation, 
which accompany their presence and frequently continue after they 
have been thus expelled, so that life is, under these circumstances, 
usually very much abridged. In all such cases, therefore, it is proper 
to operate immediately after it is fully ascertained that a foreign body 
has lodged in the windpipe, and if possible before the supervention of 



Fig. 281. From Liston. 



784 ABSCESS OF THE TONSIL. 

inflammation. The presence of the body in the windpipe, will be known 
partly from the history of the case, partly from the signs and symptoms 
present or absent ; and partly by ascertaining, by the fingers or some 
suitable instrument, that it is not in the pharynx. If it be found in the 
latter situation, it may frequently be withdrawn by the fingers ; when 
in the upper part of the oesophagus, it can generally be removed by 
suitable forceps ; or in some cases, when it is far down the gullet, and 
is of a digestible or at least not of an irritating character, it may in 
preference be pushed downwards to the stomach by the gentle use of the 
probang. But when the body, though situated merely in the pharynx, 
is so tightly fixed that it cannot be instantly withdrawn, while, by pres- 
sure on the epiglottis, or on the larynx from behind, it threatens instant 
death from apnoea, then bronchotomy must be performed, so as to 
maintain the respiration, and permit the foreign body to be extracted 
with sufficient deliberation and safety. 

The operation is also specially advisable in oedema of the glottis, 
whether acute or sudden, and more chronic and slow in its attack ; and 
either with orwithout chronic ulceration, or other disease of the larynx. 
It is also proper in idiopathic and traumatic inflammation of the larynx, 
when bleeding and other remedies fail to give relief, or at least fail to 
do so in time ; for it must be remembered, that the operation of bron- 
chotomy is not performed is these cases with the view of curing the 
disease, but only of counteracting one of its effects ; its object is, to 
prevent the arrest of respiration by a mechanical cause, until the 
disease, which has given rise to the obstruction, shall have yielded to 
nature and suitable treatment. But undoubtedly the operation, if per- 
formed at a proper distance from the seat of the inflammation, assists 
in subduing its violence, as it temporarily relieves the glottis and upper 
part of the larynx from performing their usual functions in the act of 
respiration ; and, by the local rest and relaxation thus afforded, the de- 
cline of vascular action is certainly favoured. The ultimate success of 
the operation depends very much on the period at which it is performed ; 
and it should never in these cases be delayed a moment after it is 
plainly seen, that respiration is likely to be affected, or after the signs 
of deficient aeration of the blood are observed in the commencing duski- 
ness of the countenance, and lividity of the lips. It is much more suc- 
cessful when the threatened apnoea is sudden in its attack, than 
when it slowly and gradually supervenes during disease of considerable 
duration. 

In croup, a disease in which the trachea, and very frequently the 
bronchial tubes, even to their smaller ramifications, are affected, this 
operation affords little prospect of success : but it has succeeded in a few 
cases, apparently the most* desperate, and may, therefore, be occasionally 
advisable, as a last resource. In diseases affecting the lungs alone, it is 
of course useless ; but even in these, when the immediate cause of dan- 
ger is referable to some laryngeal complication, life may be prolonged 
by the operation, a few hours, or perhaps even a few days. 

Tumours connected with the larynx or trachea, either internally or 
externally, and even when at some little distance from the air-tube, 
sometimes interfere so materially with respiration, either by the me- 



ABSCESS OF TIIE TONSIL. 735 

chanical obstructions they present, or by the frequent irritation and 
spasm of the glottis which they excite, as to render bronchotomy justi- 
fiable and necessary. 

In cases of suspended animation, whether from immersion, strangula- 
tion, hanging, or from inspiring an impure atmosphere or noxious gas, 
bronchotomy frequently aifords the only chance of recovery, by the 
quick and easy manner in which it permits the establishment of artificial 
respiration, and the insufflation of pure air. In instances of drowning, 
strangulation, and hanging, artificial inspiration may sometimes be 
maintained, without having recourse to operation, though not so satis- 
factorily or efficiently ; but in cases of poisoning by inhalation of 
noxious vapours, the glottis is often spasmodically closed, and remains 
in this state for several hours after apparent or real death, so that 
bronchotomy is here almost always necessary to permit the establish- 
ment of artificial breathing. The cerebral congestion in cases of stran- 
gulation, hanging, and poisonous inhalation, is greater than in instances 
of drowning ; and consequently there is a greater prospect of the opera- 
tion proving successful in the latter case, than in any of the former. 

Laryngotomy can be performed with much greater safety, speed, and 
facility, than tracheotomy ; and in adults, it is generally the preferable 
operation in cases of suspended animation, or when there is reason to 
believe that the upper part of the larynx alone is affected with the 
obstructive disease, or when a foreign body has lodged there. 

Tracheotomy is a more tedious and 'delicate operation, and is more 
exposed to accidental dangers from hemorrhage, and from unusual posi- 
tion of blood-vessels, than laryngotomy ; but it is the most suitable for 
the removal of foreign bodies from the trachea or the bronchi, and 
when the whole larynx, perhaps, as well as part of the trachea, is in- 
volved in the disease which obstructs respiration. 

Three situations have been recommended for the operation of laryn- 
gotomy ; but in all ordinary cases, it is restricted to one of them, namely, 
the cricothyroid membrane. The operation is exceedingly simple, and 
may be performed in the following manner : 

The head is bent back a little so as to stretch the integuments in 
front ; the depression between the thyroid and cricoid cartilages is felt 
for ; and a vertical incision of an inch or so in length is made in that 
situation, exactly in the mesial line. By this stroke, the skin, superfi- 
cial fascia, and the fibrous tissue between the margins of the sterno- 
hyoid, sternothyroid, and cricothyroid muscles, may be divided. These 
are to be drawn a little to one side, which proceeding will be facilitated 
by bringing the head slightly forwards. The cricothyroid membrane 
may then be pierced by the point of the knife, which, after having 
entered and divided the membrane from above downwards, should be 
partially withdrawn, and its edge turned quarter round, and passed in 
again so as to cut transversely, making in this manner a crucial open- 
ing. Or the membrane may be pierced by a trocar. There is usually 
very little bleeding after this operation, although a small branch from 
the superior thyroid artery of each side runs across the membrane. If 
necessary, a laryngotomy tube of suitable size may be introduced. 

Laryngotomy by cutting through the thyrohyoid membrane has been 



736 



ABSCESS OF THE TONSIL. 



proposed by Malgaigne as affording a distinct view of the interior .of 
the larynx. Such an operation may be useful for the purpose of remov- 
ing bodies lodged in the upper part of the larynx, as in the ventricles, 
or caught in the rim a glottidis ; but the opening being made above the 
rima, which is the seat of greatest constriction, it is quite unsuitable for 
any other of the ordinary purposes of laryngotomy. 

Velpeau has recommended laryngotomy to be performed by cutting 
through the thyroid cartilage ; but this operation, which offers no coun- 
terbalancing advantages, is always attended with great danger of induc- 
ing or aggravating inflammation of the larynx, and of permanently 
impairing its functions as an organ of voice ; in addition to which objec- 
tions, it would often be very difficult to accomplish, especially in aged 
persons, on account of the frequent ossification of the thyroid cartilage 
in advanced life. 

Tracheotomy is sometimes rendered a dangerous operation by the 
unusual distribution or course of arteries or veins, which occasionally 
are of no mean size. Before commencing the operation, however, the 
surgeon will be able to ascertain by his finger, whether any large artery 
is in the way, and so be prepared to avoid or secure it, as the case may 
require. 

If the object of operation be to remove a foreign body, there should 
be at hand one or more long metallic probes, which can easily be bent 
to any form, with a plentiful supply of long and short forcipes of various 

Fig. 282. 




forms and curves, having the limbs so adjusted that some may open 
laterally, and others in the antero-posterior direction, and constructed 
with points adapted for seizing the object to be extracted. In addition 
to these instruments, there should be a small sharp hook, and a curved 
"tube of a conical shape, and flattened laterally," as recommended by 
Mr. Liston. An adult patient is best placed in a sitting posture, in a 
good light, with the front of the neck made tense by the head being 
drawn back, supported on the breast of an assistant, and steadied by his 



Fig. 282. From Liston. 



ABSCESS OF THE TONSIL. 



737 



hands. A small scalpel is employed in the cutting part of the opera- 
tion, which consists, in the first place, in making an incision exactly in 
the mesial line through the skin and superficial fascia from the lower 
margin of the cricoid cartilage downwards, nearly to the top of the ster- 
num. Any blood-vessel now seen must be drawn downwards, or aside, 
and each margin of the cutaneous wound retracted a little. Any loose 
cellular and fatty tissue present should now be carefully cut through, 
but still in the mesial line. The deep cervical fascia which covers and 
connects the apposed margins of the sternohyoid and sternothyroid 
muscles, must next be divided along the centre of their line of junction 
by the point of the scalpel; and the neck being now somewhat relaxed, 
these muscles are separated and drawn a little apart by the handle of 
the instrument, and by the finger, which is employed at the same time 
to discover, by pulsation, the presence of any unusual artery. Any 
vessels here found, whether arterial or venous, must be drawn out of the 
way, and the cellular tissue cleared off in the central line by the finger, 
or the handle, or the point of the scalpel. The isthmus, or central slip 
of the thyroid body, should be drawn upwards without being wounded, 
because, especially when unusually thick, it might furnish a troublesome 
quantity of blood. At this stage, if there be much hemorrhage, and 
the case be not one of urgent haste, it will be necessary to delay the 
opening of the trachea for a few moments, until the bleeding be arrested 
by means proportioned to its amount and character ; but when possible, 
as it generally is when the mode here recommended is followed, it is 
better to finish the operation at once. For this purpose the patient is 
desired to swallow his saliva, during which action the larynx and trachea 

Fig. 283. 




are drawn upwards ; but if the patient be insensible, or if he be a child, 
not understanding or not obeying the request, the upper part of the tra- 
chea is seized by the sharp hook already mentioned, and by it is drawn up 
and held steadily. In either case, at the instant when the windpipe is 
drawn up to its utmost, the point of the scalpel, having its back directed 



Fig. 283. From Liston. 

47 



738 WOUNDS OF THE NECK. 

to the sternum, is introduced into the lowest portion of the trachea, thus 
exposing it to view, and is carried upwards so as to divide, in its course, 
three or four of the rings in the central line. 

If there be oozing to any considerable extent, the trunk and neck of 
the patient should be inclined forwards, so as to favour the outward 
escape of the blood and prevent its flowing backwards into the trachea. 
At the moment when the air first rushes in, a curious and distressing 
sensation of anxiety and alarm is experienced, but this speedily subsides. 
If the operation was undertaken for the purpose of removing foreign mat- 
ter, this should now be proceeded with. The patient's sensations usually 
refer its situation pretty correctly to a distinct spot ; and the auscultatory 
signs will confirm or correct the impression as to its precise locality. 
The probe should now be employed, so as to discover more ' exactly the 
direction and distance of the object from the external opening ; after 
which a forceps of suitable form is to be cautiously introduced, and the 
body extracted. Subsequently a tube, of the shape before described, 
which compresses the bleeding margins of the wound, and stops the 
oozing, should be introduced, until the oozing has completely ceased ; 
after which it may be removed, and the wound allowed to heal of its 
own accord, no attempt being made to close it forcibly and hasten its 
union by dragging its edges together with sutures ; at least, until the 
incision in the larynx itself has united, and the external parts of the 
wound appear disposed for adhesion, when a few plasters may be em- 
ployed to preserve apposition. 

When the operation is performed for the purpose of facilitating the 
restoration of suspended animation, or for maintaining the respiration 
during obstructive disease of the larynx, the tube may, of course, be 
introduced at once ; but great care must, in this and in every case, be 
taken by frequently cleansing the canal of the tube to preserve it from 
being closed by accumulation of mucus or other secretion. 

WOUNDS OF THE NECK. 

[Condensed from Chelius's System of Surgery, by South. 

" Wounds of the Neck either injure merely the coverings, the super- 
ficial muscles, or the deeper-lying vessels and nerves, the windpipe 
and gullet, or even the spinal-marrow. Cuts are the most frequent, and 
have either a vertical or transverse direction. If they penetrate merely 
through the skin and superficial muscles, they may be united with stick- 
ing plaster, and the union of transverse wounds on the front of the neck 
may be assisted by binding the neck forwards, but in longitudinal wounds 
it must be stretched backwards. Bleeding from the external jugular 
vein may be staunched, either of itself or by slight pressure. In wounds 
with loss of substance, or such as suppurate largely, the head towards 
the end of the cure must always be kept straight, and the sinking of the 
pus behind the breast-bone prevented. 

" Deeper penetrating wounds, in which the larger vessels are wounded, 
are usually soon mortal from the sudden bleeding. In injury of the 
carotid artery assistance is still possible if it be at once compressed by 



WOUNDS OF THE NECK. 739 

an assistant at the wounded part, the wounded end laid bare and tied. 1 
In slight injury of the internal jugular vein, the bleeding should be 
staunched by compression, or, if it be completely cut through, it must be 
compressed above the injury, and the upper end tied after proper en- 
largement of the wound. In making these ligatures sufficient care 
should be taken that the nerves lying close to the vessel, especially the 
pneumo-gastric, be not included in the ligature. The injured branches 
of the carotid artery may be tied either in the open wound, or after 
carefully enlarging it, or, if this be not possible, the principal trunk of 
the carotid is to be tied. 

" Injuries of the Pneumogastric Nerve cause loss of voice, spasmodic 
symptoms, and death. Injury of the Recurrent Nerve also causes loss 
of voice ; this, however, may occur subsequently. Injury of the Laryn- 
geal Nerve is mortal from arrest of breathing ; 2 and this is also the 
especial branch which so quickly produces death after the division of the 
whole nerve. According to Dupuy's 3 experiments, animals may live for 
some time after division of both pneumogastric nerves, if the air-tube 
be opened below the larynx ; but, if the opening be not made, the animal 
dies on account of the palsy of the nerves spreading over the muscles 
opening the chink of the glottis. If the Sympathetic or Phrenic Nerve, 
or the spinal marrow be injured, death in convulsions follows. 

" Wounds of the Windpipe are either longitudinal or transverse ; the 
windpipe may be either only cut into, or cut through, or a piece of it 
taken away as in shot-wounds. Vertical wounds of the windpipe require 
union with sticking-plaster, and that the head should be inclined much 
backwards. Transverse wounds divide it either partially or entirely ; 
they are mostly consequent on attempted self-destruction, and are 
usually found at the upper part of the neck, between the larynx and the 
tongue-bone ; penetrate to a great extent into the back of the mouth ; 
allow the air, spittle, and drink to escape through them, or even pene- 
trate into the larynx. They are rare at the lower part of the windpipe. 

" In these wounds, if the voice be at once lost, the air passes through 
the wound, frequently an air-swelling is produced, and blood flowing 
into the windpipe may give rise to dangerous symptoms. This may 
occur without the carotid artery, jugular vein, or pneumogastric nerve 
being wounded ; the bleeding may come only from the superior thyroid, 
or from the lingual artery. 

"When in transverse wounds of the windpipe the bleeding is staunched, 
the edges of the wound should be brought together by bending the head 

1 Hebenstreit; in his additions to Benjamin Bell's Surgery Abernethy's Surgical 
Works, vol. ii. p. 115. Larrey, M^moires de Chirurgie Militaire, vol. i. p. 115. Hen- 
nen, John, Observations, &c, p. 356. Collier; in the Medico-Chirurgical Transactions, 
vol. vii. p. 107. Cole; in London Med. Repository, May, 1820. Thomson, John, M.D., 
Report of Observations made in the British Military Hospitals in Belgium, &c, 1816. 
London. 8vo. Breschet ; in French edition of Hodgson's Treatise on the Diseases of 
Arteries and Veins, &c», 1815. London, vol. ii. sect. v. p. 37, note. Textor ; in Neuen 
Chiron., vol. ii. p. 2. 

2 Pye, Aufsiitze und Beobactungen aus der gerichtlichen Arzneiwissenschaft. Saml. 
vii. p. 185. 

3 Journal de Medecine, par Le Roux, etc., vol. xxxvii. p. 351. Meckel, Handbuch der 
gerichtlichen Medecin. Halle, 1821, p. 172. 



740 WOUNDS OF THE NECK. 

much forward towards the chest, in which position it is to be retained. 
This is done less certainly by bandages than by Kohler's cap ; the 
patient is at the same time to be slightly inclined to one side, so that 
the secretion may not readily flow into the windpipe. If the windpipe 
be not completely divided, the edges of the wound should not be sepa- 
rated far apart, and the position already mentioned is favourable to 
union, as the stitches excite only irritation and cough, which mostly 
hinder the union. Only when the windpipe is cut through, and the 
edges of the wound gape widely, should they be drawn together with a 
broad ligature fastening the external skin merely. 

"According to Fricke, 1 severe wounds of the neck should not at once 
be healed with the stitch ; he prefers waiting for a perfect suppuration, 
and the production therewith of new granulations, and then first puts in 
the suture to bring the suppurating edges into contact. 

(" Position in the treatment of wounds of the windpipe, at whatever 
part, is always preferable to stitches, which are really of little service, 
as from the constant drag upon them in the frequent attempts made to 
get rid of the mucus, and of the adhesive matter which begins to be se- 
creted a few 7 hours after the injury, they speedily ulcerate and are of no 
use, but rather hurtful from their additional irritation. The only real 
benefit obtained from them is that of preventing the edges of the skin 
turning into the wound, which interferes with the union ; but even in 
this attempt they often fail. Keeping the edges of the wound as near 
together as possible with strips of adhesive plaster, applied longitudi- 
nally and obliquely across the neck, and over these a roller twice or 
thrice around the neck, is all that is either necessary or proper. 

" It must, however, be recollected that even at the very first it is not 
always proper to close the edges of the wound, and the surgeon must 
therefore carefully notice, in dressing the wound, how the patient can 
breathe when the edges are brought together and covered up. Not un- 
frequently the breathing cannot be carried on by the mouth, but only by 
the wound ; under which circumstances, if the wound be shut up, diffi- 
culty of breathing and even suffocation may ensue, unless all the dress- 
ings be removed and the air allowed to escape by the wound. Its 
complete closure, therefore, must be dependent upon the freedom or 
difficulty of breathing by the mouth ; if there be no difficulty the wound 
may be carefully closed; but, if there be difficulty, a sufficient space 
must be left opposite the wound into the windpipe, to permit the free 
passage of the air. 

" Another circumstance may be also noticed as to the unneedfulness 
of stitches, that is, that these wounds rarely, if ever, unite by adhesion, 
but almost invariably by granulations, even under the most favourable 
circumstances. But the use of stitches after the establishment of the 
granulating process, as proposed by Fricke, is quite superfluous. 

" It is certainly proper at first to attempt union by adhesion, and 
sometimes the angles of the external wound will effect it ; but generally 
the parts have been so much handled in search of bleeding vessels, 

1 Fiinfter Bericbt liber die Verwaltung des allgemeinen Krankenhauses, 1832, p. 232. 



WOUNDS OF THE NECK. 741 

as well as irritated by their continual separation by the air and 
mucus forced through the wound, that the greater part of the surface 
becomes sloughy. When this happens, it is better to remove all the 
dressings, except two or three strips of plaster for support, and to sur- 
round the whole neck with a light bread poultice in a muslin bag, so as 
to prevent any of the crumbs dropping into the air-tube. — J. F. S.) 

"In these wounds there always occur severe inflammation of the 
windpipe, spasmodic symptoms, especially severe cough, which is more 
violent in injuries of the larynx than of the windpipe. If the wounded 
person have not lost much blood, he must be bled freely from a vein, 
and nitre in emulsion must be given internally. If pain and cough 
arise, bleeding from a vein (even the application of leeches) must be re- 
peated, and calomel with extract of hyoscyamus given. The food must 
be entirely fluid. Persons who have attempted self-destruction must be 
carefully watched, lest they disturb the bandages. This treatment must 
be persisted in so long as the inflammatory and convulsive state of the 
windpipe continues. 

" If union do not completely occur, the wound is to be covered with 
lappets dipped in lukewarm water. If the discharge be great, and the 
powers of the patient give way, Iceland moss, bark, and narcotic reme- 
dies, must be used. The hoarseness which remains for the most part 
gradually subsides. In injuries of the cartilaginous part of the wind- 
pipe, there sometimes remains for a long while a fistulous opening, 
which often closes of itself. When the bandage is removed, the patient 
must guard against a deep inspiration, and much drawing the head 
backwards. 

" In stabs of the Windpipe, owing to the parallelism of its inner and 
outer walls, the air readily escapes into the cellular tissue. If slight 
pressure upon the wound do not prevent the escape of the air, the outer 
wall must be enlarged with the bistoury, so that the air may more 
readily escape. 

" Bruised Wounds of the Larynx and Windpipe, Shot-ivounds with 
loss of substance, require besides the general treatment already men- 
tioned, a simple linen bandage spread over with a mild ointment. 

" If the edges of the wound skin over, and fistulous passage form, 
which especially occurs in bruises and in wounds connected with the loss 
of substance, the edges must be refreshed (repared with the knife), and, 
if possible, united vertically with the twisted suture. Attempts have 
been made to close the opening by healing over it a flap of skin. 1 

" Wounds of the Gullet occur with an entirely, or, for the most part, 
divided windpipe (in stabs only is injury of the former possible without 
that of the latter), and the gullet is either cut into or cut through. 
Severe wounds of the gullet are usually accompanied with wounds of 
the larger vessels and nerves, and are then speedily mortal. Without 
this simultaneous injury, however, wounds of the gullet may be very 
large ; it may even be entirely divided without the wound being absolutely 

1 La Lancette Frangaise, 1831, 26 Nov. Froriep's Notizen, 1831, No. 692. 



742 WOUNDS OF THE CHEST. 

fatal. 1 Injuries of the gullet in large wounds can be ascertained by 
the eye, by examination with the finger, and also by the fluid swallowed 
by the wounded person, escaping through the wound, and exciting severe 
cough. 

"When in wounds of the gullet the blood has been staunched, the 
same treatment is to be pursued as in wounds of the windpipe : the ex- 
ternal coverings must be fixed, and the head bent towards the chest. If 
the wound be large, the patient must be supported with nourishing 
clysters, baths, or what is best, by strong broths introduced by an elastic 
tube into the stomach. The elastic tube kept in the gullet should be 
about as thick as the little finger, and provided with a valve at its top. 
It is introduced through the nose or mouth ; it generally slips the first 
time into the windpipe, which must be ascertained by the motion of a 
taper flame held before the opening of the tube. In this case, the tube 
is to be drawn back, and an attempt made to pass it more backwards 
into the gullet. It may remain many days, its outer end being fas- 
tened. If the tube excite vomiting, coughing, or bleeding, it must be 
removed, and nourishing clysters and baths only used. Astley Cooper 
' objects entirely to the introduction of tubes into the pharynx and 
oesophagus, as worse than unnecessary, for they are highly injurious by 
the cough w T hich they occasion by their irritating the wound ; and, if 
adhesion or granulation have taken place to close the wound, such tubes 
tear it open again and destroy the process of restoration.' The tor- 
menting thirst of such patients is best relieved by putting into the mouth 
slices of lemon or Seville orange sprinkled with sugar. As the wound 
advances towards healing, pappy gelatinous food must be cautiously 
given by the mouth. 

" As wounds of the gullet very rarely heal by perfect agglutination 
of their edges, but the interspace is filled by the neighbouring parts, 
there usually remains some contraction at this part, or it bulges like a 
bottle, in either of which cases swallowing is difficult. 

" Stabs of the Gullet, if there be no accompanying severe injury, often 
heal without any symptoms. If the gullet be wounded at the lower part, 
the food that is swallowed may pass into the cavity of the chest. 

" Deep wounds at the back of the neck often produce a palsied con- 
dition, and also frequently a wasting of the lower limbs. Wasting of 
the testicle and loss of the generative power have also been observed in 
these cases. 

WOUNDS OF THE CHEST. 

" Wounds of the Chest are either superficial or may penetrate into 
the cavities of the chest. 

" Superficial Cut and Sabre Wounds require the same general treat- 
ment, and their union can always be produced by sticking plaster. 
Superficial Stabs (of which we satisfy ourselves by their direction, by 
the depth to which the injuring instrument has penetrated, and by ex- 
amination with the probe, after placing the patient in the same position 

1 Rust, Einige Beobachtungen iiber die Wunden der Luft und Speise rohre, nrit Bemer- 
kungen in Bezug auf ihre Behandlung und ihr Lethalitutsverhaltness, in his Magazin, 
vol. vii. p. 262. 



WOUNDS OF THE CHEST. 743 

he was at the moment of the injury, and by the absence of the symptoms 
to be described in penetrating wounds of the chest) are also to be 
treated, according to the general rules, although the more active inflam- 
mation, which usually occurs in these wounds, requires a stricter anti- 
phlogistic treatment. But when extravasation of blood takes place in 
the cellular tissue, and compression is not sufficient to staunch the bleed- 
ing, or when in the after-course of the wound a collection of pus takes 
place, and difficulty of breathing and so on occurs, the wound must be 
enlarged, the bleeding staunched, or a proper opening made for the 
escape of the pus. 

" Bruises and shot-wounds of the coverings of the chest may produce 
large outpourings of blood in the external parts, inflammation of the 
pleura and lungs, difficult breathing, spitting of blood, and so on, and 
require a strict antiphlogistic treatment, repeated bleedings, and cold 
applications to the chest. 

" Penetrating Wounds of the Chest either simply open the cavity of 
the pleura, or at the same time wound the viscera lying within the 
chest. Their danger depends generally on the bleeding which comes 
out of the walls of the chest, or from the viscera contained in its 
cavities, from compression of the lungs and heart by the collected fluids, 
from inflammation of the viscera of the chest, and their passages. 

" We ascertain that a wound of the breast actually penetrates into 
the cavity of the chest, or even injures the viscera contained therein, by 
the depth and direction to which the injuring instrument penetrates ; by 
the careful examination of the wound with the finger or with the probe, 
the patient being put into the same position as at the injury ; by the 
influx and efflux of the air through the wound in inspiration and expira- 
tion ; by an air-swelling {emphysema) which forms around the wound ; 
by difficult respiration in consequence of the air which enters the cavity 
of the chest compressing the lungs and preventing the flow of the blood. 
In simultaneous injury of the lungs the patient suffers deeply-fixed pain ; 
breathing, especially inspiration, is very difficult ; a frothy, pale-red 
blood pours in an unbroken stream out of the wound ; the patient 
spits blood (the absence of spitting blood is, however, no proof of the 
lungs being uninjured) ; sometimes also there are symptoms of internal 
bleeding and compression of the lungs, which are hereafter to be con- 
sidered. The distinction of these wounds is more or less difficult ac- 
cording to their various size and direction. 

" Examination with the probe is, in most cases, illusive and uncertain ; 
it may be very injurious, from the irritation connected with it, and is in 
most cases useless, because the diagnosis is determined by other symp- 
toms ; and in a simple penetrating wound scarcely any other treatment 
is employed than in a wound that does not penetrate. The examina- 
tion, by injection, as advised by many, is still more unsatisfactory, and 
always dangerous. 

" The air passes freely in and out only when the wound is direct. 
The lungs do not always collapse, or fall together, when the cavity of 
the chest is opened, but remain in contact with the pleura costalis, which, 
in some cases, may depend on adhesion between the lungs and the pleura. 



744 WOUNDS OF THE CHEST. 

but in others, it is not to be explained. The opening, therefore, of both 
cavities of the chest is not directly mortal. Williams concludes from 
his experiments, 1st, that the lobe of the lung when exposed to the air 
does not collapse, so long as the functions of the other lobe and of the 
assistant organs continue undisturbed in respiration ; 2d, that one lobe 
of the lung possesses a peculiar power of moving for some time, entirely 
independent of the diaphragm and intercostal muscles, when, indeed, the 
other lung respires ; the origin of this power Williams cannot determine ; 3d, 
that a sound lung recovers its natural expansive power when the pressure 
of the external air is removed ; 4th, that although the external air passes 
freely and uninterruptedly at the same time through tubes of the same 
size into the cavities of the chest, the lungs, however, do not collapse, if 
the assistant respiratory organs have their activity still unrestrained ; 
5th, that a healthy lung never completely fills the cavity of the chest, 
at least in natural respiration. In my experiments on dogs, I always 
found great collapse of the lungs, and the motions which I noticed in 
them seemed to me less dependent on a distinct expansive power in the 
lungs themselves, than much rather on elevation and depression of the 
collapsed lungs in the laborious inspiration and expiration of animals, as 
will be described in accidents of the lungs. 

"In endeavouring to determine the course which balls take when 
wounding the chest, Hennen's observation must not be forgotten, that 
' a ball striking the body or a limb will run round under the skin, and 
appear to penetrate right across the member or the cavity. By the 
deep-seated course which balls sometimes take, the deception is rendered 
still greater. Thus I have traced a ball by dissection, passing into the 
cavity of the thorax, making the circuit of the lungs, penetrating nearly 
opposite the point of entrance, and giving the appearance of the man 
having been shot fairly across, while bloody sputa seemed to prove the 
fact, and in reality rendered the same measures, to a certain extent, as 
necessary as if the case had been literally as suspected. The bloody 
sputa, however, were only secondary, and neither so active nor alarming 
as those which pour at once from the lungs when wounded. There is 
also another source of deception as to the actual penetration of balls 
into the cavities or the limbs ; this is where they strike against a hand- 
kerchief, linen cloth, &c, and are drawn out unperceived in their folds.' 

"In regard to the prognosis of wounds of the chest, Hennen observes : 
— ' I should be unwilling to lull either a patient or a surgeon into a 
false security, or to underrate the real danger of any case ; but I have 
seen so many wounds of the thorax, both from pike and sabre thrusts, 
and from gunshot, do well ultimately, that I cannot but hold out great 
hopes, where the third day has been safely got over, for though occa- 
sional haemoptysis may come on, at almost any period during a case, 
and its approach can neither be entirely prevented nor anticipated, the 
more deadly hemorrhages are usually within the first forty-eight hours ; 
and yet to this alarming symptom, when within moderate bounds, the 
safety of the sufferer is often due. Dr. Gregory of Edinburgh was in 
the habit of stating in his lectures, that of twenty-six wounds of the 
thorax received at the battle near Quebec, two only were fatal.' 

" Penetrating wounds of the chest are most conveniently treated 
under the following conditions: — 1. Simple penetrating wounds; 2. 



WOUNDS OF THE CHEST. 745 

Wounds complicated with the presence of foreign bodies; 3. Penetra- 
ting wounds with bleeding ; 4. Penetrating wounds with protrusion of 
part of the lungs. 

" Simple penetrating Wounds of the Chest, or those in -which the 
cavity of the pleura merely is opened, are rare. Their treatment con- 
sists in the speedy closing of the wound, and in the prevention of 
inflammation. The patient, after a deep inspiration, should expire, and 
then the wound is to be carefully closed with sticking plaster, covered 
with a compress, and fastened with a broad chest-bandage and a shoulder- 
bandage. The patient is to be treated on a strictly antiphlogistic plan. 
If the inflammation be prevented, the wound heals quickly. If inflam- 
mation come on and be long-continued, consecutive extravasation from 
exudation of the pleura is frequently produced after a lapse of fourteen 
days, and renders the opening of the cavity of the chest necessary. 

" Foreign Bodies, which complicate penetrating wounds of the chest, 
are either broken pieces of the injuring instrument, balls, pieces of 
clothes, driven into the wound, or splinters of the ribs. If the state of 
the injury do not itself point out the presence of foreign bodies, the 
symptoms by which it can be inferred are very equivocal. They excite 
constant irritation, difficult respiration, pain at the wounded part, even 
though the most severe antiphlogistic treatment has been long-continued; 
or although the symptoms had diminished, a fresh accession, copious 
suppuration, and so on, may occur. The circumstances of the accident 
must be carefully reviewed, in order to determine on the presence and 
position of the foreign body, which is often most decidedly possible by 
the introduction of an elastic or metallic sound, for the purpose, either 
by suitable enlargement, or by a fresh opening in the interspace of the 
ribs corresponding to its position, when it can be done, to extract it. 
The longer suppuration is kept up by a foreign body in the cavity of the 
chest, so much more difficult is its extraction, because the interspace is 
much diminished by the falling together of the ribs. Larrey 1 has in 
one such case cut out the upper edge of the lower rib with the lenticu- 
lar, as deeply as needful, for the purpose of extracting the ball, and did 
not wound the intercostal artery. 

" Bullets may penetrate the chest, run round the lungs, and pass out 
nearly opposite their point of entrance (1). Instances have occurred in 
which bullets have lain in the cavity of the chest for a long while, with- 
out producing inconvenience ; in such cases they have been enclosed in 
a covering of coagulable lymph, as in a capsule (2). 

" (1) See Hennen's Observations on this point supra p. 744. 

" (2) In one case the ball remained in the substance of the lung for 
twenty years, the patient continuing in good health, and no symptoms 
occurring to indicate its position. In another, the ball rolled about in 
the cavity on every motion of the body. 2 

" In penetrating wounds of the chest bleeding may occur from the 
arteria intercostalis, the arteria mammaria interna, from the lungs, or 
from the great vessels of the chest. In large and direct wounds the 
blood flows out freely ; if the wound be narrow, if it form a long, and, 

1 Memoires de Chirurgie Militaire, vol. iv., p. 250. 

2 Mangetus, Bibliotheca Chirurgica. Geneva, 1721, folio. 



746 WOUNDS OF THE CHEST. 

perhaps, curved canal, the blood empties itself into some one space 
internally, and the quantity poured out is relative to the size of the 
wounded vessel, and the space in which the effusion has taken place. 

" Under such collection of blood in the cavity of the chest the face is 
pale, the pulse small and quick, the countenance shrinks, there is sing- 
ing in the ears, cold sweats over the whole body, exceedingly difficult 
breathing, danger of suffocation ; that side of the chest in which is the 
extravasation is more full and moves less during respiration ; the patient 
breathes best on his back, with the upper part of his body raised ; suf- 
focation threatens if he lie on the sound side. As the extravasation 
increases, the symptoms become more severe, and the patient dies suffo- 
cated. 

" The symptoms of extravasation of blood in the chest are very 
different and often very equivocal. If the extravasation be slight, or if 
it have been slow in its production ; if the lung be adherent with the 
pleura to a great extent; if the individual be less sensible on account 
of the loss of blood ; if previous disease of the chest exist ; if spas 
modic symptoms accompany the injury, then the diagnosis is extremely 
difficult. 

" The most certain and determinate signs of extravasation of blood 
in the chest are, the continued symptoms of an internal bleeding, diffi- 
cult, quick and short breathing, with spitting of blood in wounds of the 
lungs, in which inspiration becomes easier and expiration more difficult, 
and in sleep threatens suffocation ; constant anxiety in a greater or less 
degree ; difficulty or utter incapability of lying on the sound side ; a 
dull sound on percussion of the chest, increasing with the increase of 
extravasation ; the respiratory murmur accompanied with a gurgling 
murmur, and in a severe case of extravasation subsiding entirely, or 
perceptible only at the upper part of the chest ; a tolerable condition 
when lying on the back with the chest much raised ; irregular action of 
the heart and pulse ; loss of sleep ; pale, sparing, and even suppressed 
urine. 

"The less certain and constant symptoms are, increased expansion of 
the wounded side of the chest, by which the ribs are separated from 
each other, and their mobility interfered with ; ©edematous swelling of 
the chest (in some parts at least the muscles appear more full) ; in the 
greater extent over which the pulsation of the heart can be felt, and its 
displacement to the opposite side by the pressure of the fluid ; a sensa- 
tion of weight on the chest, or an audible squash on the patient's mo- 
tions ; a swelling beneath the short ribs and in the region of the belly, 
from depression of the diaphragm ; ecchymosis on the short ribs of the 
injured side, first occurring some days after the accident ; oedema of the 
hand and foot, and redness of the cheek upon the injured side. 

" The existence of extravasation may be distinguished with certainty 
when the symptoms described, or if not all, yet the most part of them 
appear together, continue, and increase ; if they be unaccompanied with 
any other organic affection, and do not yield to general treatment in the 
first twenty-four hours. 

" The blood extravasated into the cavity of the chest operates not only 
as a mechanical hindrance to respiration by compression of the lungs, 



WOUNDS OF THE CHEST. 747 

so that they gradually lose their cellular character, and unite with the 
pleura ; whence it happens that, after long-continued extravasation, its 
discharge is of no use, the lung being no more capable of expanding 
itself ; inflammation of the surface, with which it is in contact, also soon 
takes place, as the blood operates fatally by its decomposition, though 
it often continues long in its naturally fluid state. The bleeding must 
therefore be staunched, the further extravasation be prevented, and the 
effusion into the chest removed. 

" 'In incised or punctured wounds, hemorrhage takes place,' observes 
Hennen, ' instantaneously, and profusely ; in gunshot wounds, if the 
intercostal artery or lungs are only brushed, or some of the more minute 
vessels opened, it is not so violent ; and we have rather to prepare for 
what may occur on the separation of the eschars, than to combat any 
existing symptoms, the general tendency to pneumonic inflammation 
excepted. In the event of secondary bleeding from the lungs them- 
selves, we are in possession of no external means for remedying it ; but 
whenever the tenaculum can be used to an injured intercostal artery, it 
should at once be applied, and the vessel secured by ligature. Unfor- 
tunately, however, we but too often are disappointed in finding the 
source of the hemorrhage ; and here judicious pressure is our only 
resource. In some slight injuries I have used the graduate 1 compress 
with success ; but if the sloughing is extensive, nothing but the finger 
of an assistant, relieved as often as occasion may require, and pressing 
direct upon a compress placed along the course of the vessel, or so dis- 
posed as to operate upon its bleeding orifice, will be of any avail.' 

" It is very difficult in most cases, in many quite impossible, to deter- 
mine the origin of the bleeding in penetrating wounds of the chest. 

" Injury of the Intercostal Artery may be presumed when the wounded 
person does not spit blood, and when the symptoms of extravasation 
are urgent. If the wound be large, bright-red but not frothy, blood 
spirts from the wound in an unbroken stream ; if the finger be put on 
the point where the artery is wounded, its spirting may be felt. The 
wound is directed towards the lower edge of the rib. 

" We are rich in remedies proposed for staunching bleeding from the 
intercostal artery, but equally poor as to the effects which determine 
their fitness and applicability. To these belong the tying round of the 
rib according to Gerard, 1 Goulard, 2 and Leber ; 3 the tying the artery 
(without the rib) by means of an armed needle, jointed at its fore part, 
after the manner of Reybard and Nevermann ; its immediate ligature 
proposed by Ben. Bell ; 4 the compression of Lottery, 5 Quesnay, 6 Bel- 
loq, 7 and Harder ; 8 the compressors of Desault and Sabatier, 9 by means 

1 Dionis, Cours d'Operations de Chirurgie, par De la Faye, Paris, 1771, p. 341. 

2 Memoires de l'Academie des Sciences, an. 1740. 

3 Plenck, Sammlung von Beobachtungen, vol. ii. p. 210. 

4 System of Surgery, 3d Edit. Edinburgh, 1787. 

5 Memoires de l'Acajlemie de Chirurgie, vol. ii. 

6 Dissertatio de Haamorrhagia Arteriae intercostalis sistenda. Berol., 1823. 

7 Medicine Opcratoire, vol. 1., p. 179. 

8 Neue Bemerkungen und Erfahrungen Berlin, 1781, vol. i., p. 59. 

9 Manuale de Chirurgia. Milano, 1812. 



748 WOUNDS OF THE CHEST. 

of a square piece of linen, of which the middle is so deeply thrust into 
the wound and fitted with charpie, that if the ends be pulled the middle 
is pressed as a plug against the artery ; or by a proper thick plug, fur- 
nished with a strong thread, passed through the wound, and, by means 
of the thread brought to the rib. According to Medin the wounded 
vessel should be completely cut through with a myrtle leaf, pushed back, 
and a tent pressed upon it. Assalini proposes cutting the artery 
through, and allowing it to retract ; to close the wound carefully, and 
subsequently to discharge the existing extravasation. 

" To employ the greater number of the plans of treatment recom- 
mended and above described, for staunching bleeding of the intercostal 
artery, a large wound is always needed, and if the wound be not large, 
it must be increased. They are generally to be considered as exceed- 
ingly dangerous proceedings, the result of which is always uncertain. 
If the uncertainty be remembered, in which the surgeon generally finds 
himself as to the source of the bleeding, and that in simultaneous 
injury of the lungs, the bleeding from those organs is increased by the 
employment of most of these remedies, the application of immediate 
ligature or of compression must Qot be unconditionally recommended. 
Injury of the intercostal artery, near the breast-bone or in the middle 
of the ribs, where most wounds of the chest occur, does not always 
produce severe bleeding, as foreign and home practice proves. 1 The 
injury of the intercostal artery, near its origin, always indeed causes 
very dangerous bleeding ; but in this case also, on account of the depth 
of the artery, and also the knowledge of the source of the bleeding, 
is the application of the preceding means difficult and indeed impos- 
sible. 2 

"It is most suitable, therefore, in bleeding from the intercostal 
artery, to employ only such treatment as is pursued when the bleeding 
is from a vessel of the lungs, and to hope that by closing of the wound, 
by strict antiphlogistic treatment, by cold applications to the chest, by 
the pressure of the blood retained in the cavity of the chest, the 
wounded artery will become closed with a clot, after which the extrava- 
sation may be discharged in the usual way. Only in large, open wounds 
is the immediate ligature of the intercostal artery possible. If the 
pleura be not wounded at the same time with the intercostal artery, it 
may be attempted to staunch the bleeding by filling the wound with 
charpie. 

" Wounds of the Internal Mammary Artery must be distinguished on 
anatomical principles and by examination, as in wounded intercostal 
artery. Between the fifth, sixth, and seventh ribs it must be nearly 
always accompanied with a division of the rib-cartilage ; and it may be 
wounded without effusion of blood into the cavity of the pleura. 

" What has been said in reference to staunching bleeding from the 

1 Ravaton, Pratique Moderne de la Chirurgie. Paris, 1785, vol. ii., p. 130. Spiess, 
above cited. 

2 Chelius, Ueber die Verletzung der Art intercostalis in gerichtlich medicinischer 
Hinsicht; in Heidelberger klinisch Annalen, vol. i., part iv., also vol. iii., part ii., and 
in Spiess, above cited. See also Von Graefe, Bericht uber dasklinische chirurgisch- 
augen-arztliche Institut der Universitat zu Berlin fur das Jahr 1826. Berlin, 1827. 
And in Journal fur Chirurgie und Augenheilkunde, vol. x., p. 3G9. 



WOUNDS OF THE CHEST. 749 

intercostal, in part, also, applies to that from the mammary artery. It 
may, perhaps, be taken up on the second, third, and fourth intercostal 
spaces. As to the other modes of treatment, only compression, by 
means of folds of linen filled with charpie, and the remedies advised for 
staunching bleeding from the lungs are to be employed. 

" When the large vessels in the cavity of the Chest are wounded, the 
person dies quickly ; only when the wound is small can he live for a 
little time. If no very large vessel be wounded, the symptoms vary. 

" If the lungs be wounded at a part where they are connected with 
the pleura, there will not be any effusion into the cavity of the pleura, 
and that space only made by the wounding instrument into the lungs 
will be filled with blood ; it flows out, if the external wound be suffi- 
ciently large, or filters into the cells of the lung itself. But if the lung 
be wounded at an unattached part, the blood will flow into the cavity of 
the pleura, and the symptoms already described will be produced. 

" The staunching of bleeding from wounded lungs can only be effected 
indirectly. 

" 1. The power of the circulation must be so reduced by the most 
strict antiphlogistic treatment, by large repeated bleedings, that by the 
greatest quietude of the patient, by continued use of cold application to 
the chest, and cooling medicines, a plug may be formed in the opening 
of the vessel, which, under the weakened circulation, cannot be thrust 
out by the force of the moving blood, and consequently the wounded 
vessel is obliterated. The bleeding must therefore be so often repeated 
as the pulse begins to rise and to threaten, by the increased motion of 
the blood, the thrusting out of the just formed clot. 

" 2. The blood must be retained in the cavity of the chest, partly for 
the purpose of assisting the formation of the plug, partly to prevent its 
early throwing off. The wound must be, therefore, as already said, 
well closed with sticking plaster. If under this treatment the bleeding 
stop, of which we become aware by the cessation of the primary symp- 
toms, by the return of the natural warmth, and so on, and the symptoms 
of extravasation still continue, then, after two or three days, we must 
proceed to open the cavity of the chest. Only when there is manifest 
danger of suffocation is this to be done earlier ; in which case, however, 
a repetition of the bleeding is always so much earlier to be feared. 

"Emphysema is that swelling which arises from the escape of air 
into the cellular tissue. It only rarely occurs in large and direct 
wounds ; more commonly in those of which the external opening is not 
wide, and which have an oblique direction, as in stabs ; and it is very 
common in broken ribs, when the bony points penetrate the lungs, and 
in shot-wounds, on account of the great swelling which closes the exter- 
nal opening. 

" Emphysema takes place when the air penetrates through the exter- 
nal wound into the chest, and on account of the outer and inner wound 
not being parallel, is driven into the cellular tissue ; or in wounds of the 
lungs when the air is driven through the cells of the lungs into the 
cavity of the pleura, and thence through the wound into the cellular 
tissue. In the former case the swelling is not large, and does not 
spread beyond the circumference of the wound ; in the latter the swell- 



750 WOUNDS OF THE CHEST. 

ing is much more extensive and may spread over all parts of the body, 
the palms of the hand and the soles of the feet excepted, in consequence 
of which the patient has a frightful appearance. Emphysema is readily 
distinguished from all other swellings by the natural colour of the skin 
covering it, and by its peculiar crackling sensation when touched. 

"When the air escapes from the lungs into the cavity of the pleura, 
and there collects, the same symptoms of compression of the lungs are 
produced as in extravasation of blood. Breathing is disturbed, and 
becomes extraordinarily difficult ; the patient sits up, and bends for- 
wards ; the countenance becomes reddened and swollen, the pulse small 
and contracted ; the extremities cold, and the oppression will quickly 
destroy the patient. 

" If the emphysema be not very great, merely confined to the neigh- 
bourhood of the wound, it may be got rid of by the application of dis- 
persing remedies. If it be greater, and raise the skin from the muscles, 
deep scarifications must be made in different parts, and the air dis- 
charged by squeezing. If suffocation threaten, the wound must be en- 
larged or a fresh but direct one made into the chest, by which the air 
passing from the lungs may freely escape. By enlarging the wound, or 
by opening the chest at another place, merely pressure on the lungs is 
prevented. Abernethy considers the application of a broad chest-ban- 
dage especially advantageous in emphysema, in order to prevent the 
motions of the chest. 

" Protrusion of a Portion of the Lung in Wounds of the Chest is 
rare. It cannot arise, as has been falsely held, 1 from expansion of the 
lungs, but from the air in expiration streaming violently out of the 
wound, which as it is partially behind the lungs, forces, by its violent 
escape, the edge of one or other lobe of the lung into the wound. 
At least in animals I have never seen any other part protruded. 2 If 
the protrusion be recent, the lung healthy, and the condition of the 
wound permit, it must as quickly as possible be gently returned. In 
general it is necessary to enlarge the wound for this purpose. To pre- 
vent its reprotrusion, the wound must be properly closed and covered 
with a compress, which is to be fastened with a bandage. If the pro- 
trusion have existed long, if the protruded part be in a state of gangrene 
from the constriction, a ligature must be put on its base, and the pro- 
truded gangrenous part cut off in front, or left to itself. 

" ' The sinking of the lung is not,' according to Hennen, 'a uniform 
consequence of a penetrating wound of the thorax. We have sometimes 
occular proof of this, not only by the close contact in which the lungs 
lie to the wound, discoverable at first sight, but by protrusions which 
occasionally happen, and which, in the hands of the older surgeons, were 
removed by the knife, — a practice now rejected, and gentle pressure 
substituted.' 

" Inflammation of the Lungs and Pleura, which are always to be 
feared in penetrating wounds of the chest, must be prevented or mode- 
rated by the strictest antiphlogistic treatment. The patient must be 

1 Richter, Anfangsgriinde, vol. iv., p. 441. — Mayow, De Respiratione, Lugd. Batav., 
1671, p. 5. — Halliday, Observations on Emphysema. London, 1807. 

2 Spiess, above cited. 



WOUNDS OF THE CHEST. 751 

kept in the greatest bodily and mental quiet : he must not speak ; and 
take only cooling drinks and food. Nitre is to be given internally, at- 
tention paid to keeping the bowels open, and repetition of the bleeding 
as often and as largely as the condition of the patient may seem to 
require. 

" Inflammation of the lungs and pleura may proceed to infiltration of 
the lungs with blood, to suppuration, or serous effusion into the cavity 
of the pleura. The suppuration of the lungs forms an abscess, which 
empties itself either by the mouth or into the cavity of the chest. In 
the latter case, and in serous collections in the cavities of the pleura, 
symptoms of extravasation appear, and opening the chest becomes 
necessary. 

" ' Inflammation of the lung,' says Astley Cooper, * is to be guarded 
against by large and repeated bleedings, determined by the dyspnoea 
and hardness of the pulse ; but there is little danger of bleeding too 
much in one of these cases, as it is an object not only to diminish the 
force of the circulation, but the quantity of blood in the pulmonary ves- 
sels. If effusion follows, it is the result of neglected inflammation, or 
of having closed the external wound too early. In the one case it is a 
purulent secretion ; in the other a bloody serum, which produces the 
dyspnoea some days after the accident. For effusion into the chest, it 
is right to perform the operation for paracentesis thoracis, to draw off 
the pus or bloody serum which has collected. * * * In old persons 
there is great danger in fractured ribs with wounded lungs, and I always 
give a guarded opinion, for I have seen several die from effusion of fluid 
into the cellular tissue of the lung. The greatest care and quiet are 
therefore required in such a case, and it is better to give digitalis than 
to bleed very largely.' 

" The symptoms of inflammation of the lungs and pleura, when they 
become severe, have great resemblance to those of extravasation. The 
circumstance distinguishing them is, that the symptoms of inflammation 
diminish after properly employing antiphlogistic treatment, whilst those 
of extravasation continue or increase. 

" Wounds of the Heart are fatal, either suddenly by the bleeding, or 
the danger depends on the contraction of its fibres, if only some of 
them be divided, on the collection of blood in the pericardium, and on 
the difficulty of cure from want of rest, and the consequent addition 
and extension of inflammation. Only slight wounds of the pericar- 
dium and of the heart are curable when the inflammation has not been 
great ; at least distinct scars from previous injuries have been observed 
on the pericardium and on the surface of the heart. 1 Cases, however, 
have occurred of wounds of the heart which have healed, in which 
several days after the injury, and independent of it, death has taken 
place, and the bullet been found in the heart. 2 

" We presume that the heart is wounded from the direction and depth 
of the wound. The peculiar symptoms given of this injury are, a more 
or less severe pain in the region of the heart, extraordinary restlessness, 

1 Richerand, Nosographie Chirurgicale, vol. iv. p. 3. 

2 Diet, des Sciences Medicales, vol. iv., p. 217. Penada, Saggi scientifici e litterari 
di Padova, 1794, vol. iii., part ii. p. 60. 



752 WOUNDS OF THE CHEST. 

and insupportable anguish ; irregular intermitting pulse ; cold extremi- 
ties, cold sweat, and frequent faintings. The bleeding varies as the 
wound is superficial or deep ; in both cases it may be absent on account 
of the peculiar contraction of the muscles, especially in oblique wounds. 
The blood either pours forth externally, or into the pericardium, or into 
the chest, with symptoms of extravasation and of internal bleeding. 
Special symptoms of wound of the pericardium and of the surface of the 
heart are not describable, and equally indistinguishable are the symp- 
toms of the parts wounded. Perhaps the different colour of the blood 
in wounds of the left and right side of the heart might render a diagnosis 
probable. The right] ventricle is most frequently wounded. Wounds 
of the arteries are as dangerous as those of the ventricles ; in them a 
small wound may be closed by contraction of the muscular fibres. 

" Only the most strict antiphlogistic treatment can in these wounds 
be employed. If extravasation into the pericardium take place, the 
making an aperture in it is the only though very doubtful remedy. 

" Wounds of the pericardium sometimes occur without injury of the 
heart, and may be fatal. 

"Wounds of the diaphragm, especially of its tendinous part, are 
always accompanied with the most severe pain, anxiety, cramps, and 
convulsions, against which a strictly antiphlogistic treatment must be 
employed. If the wound in the diaphragm be large, the intestines of 
the belly may pass through the opening into the cavity of the chest." — 
Ed.] 



753 



CHAPTER XXIY. 
TUMOURS. 

A correct classification of tumours has always been acknowledged 
to be extremely difficult. In a histological point of view, they have 
been arranged into two grand divisions, namely, First, homologous, 
homoeomorphous, non-malignant, or benign ; Second, heterologous, hete- 
romorphous, or malignant. 

The first class comprehends those whose structure histologically 
agrees with that of some normal tissue. To this class belong, among 
others, fatty, fibrous, cartilaginous, and osseous tumours. Homologous 
tumours resemble normal textures in their histological composition, in 
their origin, in their mode of growth, and in forming persistent consti- 
tuents ; they do not depend on constitutional cachexy, are not apt to 
return, and have no tendency to convert surrounding textures into struc- 
tures resembling their own ; hence they are said to be non-malignant or 
benign. When tumours belonging to this class prove injurious, it is 
principally owing to their size, or to pressure on surrounding parts ; and 
when they become the subjects of inflammation, it is owing to exposure 
to mechanical injury, or to irritation caused by pressure, or to some 
other external cause, and not to their own nature, or histological ele- 
ments. 

The second class comprehends those whose elements may be con- 
sidered histologically to differ from those of the normal body, and which 
have a tendency to extend to surrounding parts, and change them into 
structures resembling their own ; and from the very nature of their his- 
tological elements, have a tendency to proceed to softening. Carcino- 
matous and medullary tumours may be mentioned as examples of this 
class. They have also a tendency to return after extirpation, and are 
connected with constitutional cachexy. 

In regard to the malignancy or non-malignancy of tumours, Vogel 
makes the following remarks : — " It has not always been clear wherein 
consisted the malignant, or non-malignant character of a tumour. It 
has been generally agreed, that the non-malignancy of a tumour con- 
sisted in the circumstance, that it would not be reproduced after extir- 
pation ; those which after extirpation were again produced, being held 
to be malignant. This view I regard as incorrect ; tumours which are 
manifestly non-malignant, as, for instance, encysted tumours, may again 
reappear through the same originating force which first produced their 
development ; whilst tumours notoriously malignant may never return 
after extirpation, or may even vanish of themselves, provided that the 
disposition to their formation no longer exists, as has been undoubtedly 

48 



754 TUMOURS. 

shown in relation to the pulmonary tubercle. The malignity, which 
forms the grand division between these two classes of tumours, is con- 
nected with the very nature of the tumour itself, and depends on its 
histological elements." 

Although objections have been urged against this division of tumours, 
inasmuch as some, tubercular tumour for example, may be as justly an- 
nexed to the one class as to the other, having some characters common 
to each, it has notwithstanding been considered by some of our best 
authorities to b.e more practically useful, and more conformable to 
nature, than any other classification as yet brought forward. 

I. HOMOLOGOUS, HOMCEOMORPHOUS, NON-MALIGNANT, OR BENIGN 

TUMOURS. 

I. SIMPLE SARCOMA. 

Under this appellation have been comprehended simple enlargements, 
or hypertrophies, of organs ; as, for example, simple or chronic enlarge- 
ment of the mammary gland, testicle, or thyroid gland, — conditions in 
which the natural elements of the normal structure, though in an in- 
creased and altered condition, may be recognised by the aid of the 
microscope. But the term, simple sarcoma, has also been applied to 
tumours independent of special organs, which, it is believed, are formed 
by the change of exudation into cells and fibre cells. These ultimately 
assume the appearance of areolar tissue ; vessels are developed, and the 
structure becomes incorporated with the tissue from which the exudation 
had taken place. 

II. FIBROUS TUMOUR. 

Seats. — Fibrous tumours occur in many different situations, but most 
frequently in the neck, in the neighbourhood of the parotid gland, in 
the uterus, in the neighbourhood of the mammary gland, in the skin, 
forming warts, in the nostril, constituting fibrous polypus, and connected 
with periosteum in other parts of the body. The uterus, nerves, sub- 
cutaneous cellular tissue, bones and periosteum about the jaws, are their 
most common seats. 

Professor Paget, in his exceedingly interesting lectures on tumours, 
delivered at the Royal College of Surgeons of England, a few months 
ago, remarks regarding fibrous tumours : — " The usual distinction must 
be drawn between the tumours and the outgrowths of the same structure. 
The uterus presents examples of both. The fibrous uterine polypi, more 
properly so-called, are continuous outgrowths of, and from the substance 
of the uterus ; the mucous membrane and the muscular and fibrous tis- 
sues of the uterus, growing in variety of proportions into its cavity and 
that of the vagina. The fibrous tumours, as distinguished from these, 
are discontinuous growths of similar tissue, in or near, but not of the 
substance of the uterus. The distinction is often difficult to make during 
life ; for the pendulous, polypoid, and narrow-stemmed outgrowth may 
be imitated in all its external characters by a tumour growing near the 
surface of the uterus, and projecting into its cavity, with a gradually 
thinning investment of its muscular and mucous tissue." 



TUMOUKS. 755 

Characters. — Fibrous tumour is slow in its growth ; is unattended 
with pain or tenderness, unless accidentally inflamed ; is extremely 
hard, globular in form, with its surface smooth or lobulated ; is mova- 
ble, and is enclosed in a cyst of condensed cellular tissue, by which it 
is separated from the surrounding parts. When situated in the neigh- 
bourhood of a gland, such as the parotid or mammary, it causes absorp- 
tion ; and from this circumstance comes apparently to occupy the situa- 
tion of the gland ; so that an incautious observer might be led to mistake 
the tumour for a disease of the gland. The tumour causes incon- 
venience, principally by its size and by pressing on surrounding parts, 
and, like all non-malignant tumours analogous to the normal elements 
of the body, by becoming the subject of inflammation, ulceration, and 
softening. These changes are produced by the influence of causes which 
are not inherent in its nature, but exoteric and accidental. 

Fibrous tumours present considerable varieties in the histological ar- 
rangement of their fibres. In some cases the fibres resemble those of 
ligament, as in what is called the 

desmoid tumour ; in some of a very Fi S- 284 - 

firm elastic character, the fibres are 
compressed into a very solid mass, 
and are with great difficulty sepa- 
rated, as in what is termed the fibroid 
tumour ; in some, the fibres are so 
compressed and firm, and the tu- 
mour is so uniform, having a homo- 
geneous and white appearance, that 
this variety has been named chon- 
droid tumour, from its resemblance 
in appearance to cartilage, although 
histologically its structure is quite 
different ; in some, the fibres are arranged in concentric circles, present- 
ing a most beautiful appearance when examined by the microscope ; and 
in some, they run irregularly in every direction. By the characters 
mentioned above, and by the absence of the usual signs of carcinoma, it 
is generally easy to distinguish this form of tumour from cancer ; but when 
it is not so, the diagnosis can only be established by the use of the explor- 
ing needle and the microscope ; the presence of fibres and the absence 
of cancer cells will reveal the nature of the tumour. In some large 
fibrous tumours, especially in the uterus, calcareous salts are sometimes 
deposited, and these unorganized concretions have by some been incor- 
rectly regarded as formations of bone. Another change met with in 
this class of tumours, is the formation of cysts. This has been thought 
to be due, in some instances, to the local softening or liquefaction of 
part of the tumour, or to an accumulation of fluid in the interspaces of 
the intersecting band ; in others, to a process of cyst formation corres- 
ponding to that in eystic disease of the breast. These two changes have 
suggested to some the names of the "fibro-calcareous," and the " fibro- 
cysted" tumour. 

Fig. 284. Section of a desmoid fibrous tumour of the uterus, after the addition of 
acetic acid. — From Bennett. 




756 TUMOURS. 

A multiplicity of fibrous tumours is not unusual in the nerves and the 
uterus, but in other situations they are single. 

Treatment. — The proper treatment is removal at an early period, and 
in most of the situations, the only proper proceeding for accomplishing 
removal is excision. The preferable mode of effecting removal in the 
case of fibrous tumour of the nostrils, constituting fibrous polypus, has 
already been described in the section on Affections of the Nose. 

III. FATTY TUMOUR. 

Professor Paget remarks, " There are both continuous and discon- 
tinuous morbid hypertrophies of fat ; both fatty outgrowths, and fatty 
tumours, more properly so called. M. Lebert distinguishes- the fatty 
tumours according to their degrees of isolation, as Lipoma circumscrip- 
tum, and Lipoma diffusum." 

Seats. — Fatty tumour is found in all parts of the body, and at all pe- 
riods of life, but most frequently under the common integument of the 
trunk, thighs, and shoulders ; and although quite usual in both sexes, it 
is oftener met with in females than in males. A remarkable fact is, that 
they sometimes leave the spot where they began to grow, and take up 
another position. 

Characters. — The principal characters of this tumour are, that it is 
painless, lobulated, elastic to the touch — which elasticity sometimes 
simulates fluctuation — exceedingly movable, and has the characteristic 
softness and pliancy of fat. The simple form, called simple lipoma, 
feels much lobulated ; the encysted form feels globular and doughy, and 
is but loosely connected with surrounding parts. By these characters 
the diagnosis is generally made very easy. From deep-seated abscess, 
and from encephaloma, this form of tumour is distinguished, not only 
by the symptoms just described, but also by the absence of the charac- 
teristic signs of those affections. 

Varieties. — There are several varieties of 
Fi g- 285 - fatty tumour: 1. Lipoma simplex, the true 

fatty tumour, with little appearance of areo- 
lar tissue. 2. Lipoma mixtum, in which the 
fat cells are more or less separated from 
each other by penetrating portions of areo- 
lar tissue. In some cases, as in simple 
lipoma, the fat cells are diffused among, not 
distinctly separated from, surrounding parts ; 
but in most, there is a fine cyst of cellular 
tissue to which the tumour is very loosely 
attached ; but sometimes it is thick, and so 
much so as to give the appearance of an en- 
cysted tumour, although, the cyst and its contents being connected by 
organized structure, the essential condition of an encysted tumour is 
wanting. 3. Muller describes what he calls Lipoma arborescens, " rami- 
fying productions consisting of fatty tissue, and occurring in the joints, 
especially in the knee-joint. Growths of this sort are covered by a pro- 
longation of the synovial membrane, and hang loosely in the cavity of 

Fig. 285. Structure of a fatty tumour removed from the back. a. Isolated cells, 
showing crystalline nucleus of margaric acid. — From Bennett. 




TUMOURS. 757 

the joint, forming arborescent tufts somewhat swollen at their extre- 
mities." 

The state of parts in simple lipoma is described under the head of 
Lipoma of the Nose. 

Treatment. — All attempts at discussion should be avoided, as being 
not only useless, but calculated to be injurious, by exciting irritation, 
inflammation, adhesions, incorporation with surrounding textures, 
and perhaps degeneration of the tumour. Removal by operation, 
than which few things can be more easy, is the only judicious proceed- 
ing. The cyst having been opened by incision, evulsion of the tumour 
is very readily effected by the finger alone, or by the finger and an 
occasional touch of the knife ; dissection may be said to be scarcely re- 
quired, unless incorporation with surrounding parts, adhesions or degene- 
ration have been previously produced by stimulation or some other kind 
of injudicious treatment. The operation for lipoma of the nose has 
already been described. 

IV. ENCYSTED TUMOURS. 

Synonyms. — Encysted tumour, cystic tumour, and cystic sarcoma. 

Seats. — Encysted tumours are met with in many different situations, 
but are most frequent in the mamma, in the testicle, and under the 
common integument of the head and face ; they are comparatively rare 
in the limbs. 

Characters. — It has been already stated, that fibrous and fatty tu- 
mours are found enclosed in cysts. In all such cases, the cysts consti- 
tute the means of connexion between the tumour and the surrounding 
parts, and an organized structure connects the cyst and its contents 
with each other ; but the distinguishing peculiarity of those tumours to 
which alone the term encysted is applied, is that they have no organized 
means of connexion between the cyst and its contents. Encysted 
tumours are generally more or less of a globular form, unattended with 
pain or tenderness ; the surface is usually unequal ; the tumour feels 
solid at some parts ; and there is more or less of fluctuation, depending 
on the number, size, and contents of the cysts. 

Varieties. — Encysted tumours present great varieties, the principal 
of which are the following : — 

First. Cystic tumours with simple cysts, the cysts being smooth or 
only marked by a few eminences. The cysts in different tumours differ 
much in thickness and in their contents, which are sometimes thin and 
watery, sometimes glairy, sometimes gelatinous, sometimes of a blackish 
appearance. In some instances where there has been irritation, they 
are of a purulent character ; in others, they consist of various extractive 
matters and salts ; sometimes they are of the consistency of honey, 
pap, or lard, and hence the terms meliceritious, atheromatous, or stea- 
tomatous. In some rare cases, the cysts have been found to contain 
hairs, teeth, horny -structure, and true bony substance. This variety is 
named cystosarcoma simplex. 

Second. The parent cysts in many instances contain smaller cysts 
in their interior, attached to the walls by pedicles. This variety has 
been called cystosarcoma proliferum. 

Third. A third variety is called cystosarcoma phyllodes, " in which 



758 



TUMOURS. 



the cysts, included in a sarcomatous substance, are ill-defined, form 
several cavities and chambers without a distinct proper membrane, 
and are filled more or less completely with solid, foliaceous cauliform 
growths from the floor and walls of the cavity. This form corresponds 
with the cystic formations, where solid granulations spring exuberantly 
from the walls of the cyst." 

Treatment. — The proper treatment is to remove the tumour by exci- 
sion ; but the mode of proceeding varies in some respects according to 
the situation of the tumour and its firmness of connexion with the sur- 
rounding parts. If it be loosely adherent, as is usually the case when 
it is situated under the scalp, removal may be very quickly effected by 
making a longitudinal incision of the integument without opening the 
cyst ; and the cyst and its contents may then be very quickly removed 
by pressing the integument on each side of the tumour, or by the use 
of a hook or forceps, or by pressing it out with the handle of the instru- 
ment. If the cyst and superimposed integument be at any part firmly 
adherent, it is better to commence the operation by making an elliptical 
incision comprehending the adherent part of integument. If the cyst 
be firmly incorporated with the surrounding parts, then, in some situa- 
tions, dissection is preferable to any of the above-named methods of 
evulsion, and in others the sac should be opened and its interior touched 
with nitrate of silver. And if the whole of the cyst in any particular 
case cannot be removed, as is not very unusual when these tumours form 
in the eyelids, it should be touched with a small bit of caustic to insure 
its destruction. 

V. CARTILAGINOUS TUMOUR. 

To the valuable and elaborate investigations of J. Miiller we are 
indebted for much information on cartilaginous tumours, which he desig- 
nated by the term enchondromata. Chondroma, Enchondroma, Osteo- 
chondroma, and Benign Osteo-sarcoma are some of the names which 
have been applied to this tumour. 

Seats. — Enchondromata may take place in the soft parts or in bone. 
Examples of the former are comparatively rare. 
J. Miiller met with only four in thirty-six cases 
of cartilaginous tumour ; and of these four, one 
was in the mamma, one in the parotid gland, 
and two in the testicle ; glandular structures 
being the only soft parts in which he found 
the disease. Its most frequent seat in the soft 
parts is in or near the parotid gland. Of en- 
chondroma of bone there are two varieties ; cen- 
tral enchondroma in the interior of bones, com- 
mencing in the centre of the bone, and enclosed 
in a thin bony case ; and peripheral enchon- 
droma, beginning on the surface, and furnished 
only with a fibrous covering from the perios- 
teum. 
This disease is very common on the metacarpal and metatarsal bones ; 



Fig. 286. 




Fig. 286. From Druitt. 



TUMOURS. 759 

on the phalanges of the fingers and toes ; on the femur and tibia near 
the knee joint ; on the humerus, the bones of the pelvis, and the 
ribs; indeed there is scarcely a bone on which cartilaginous tumours 
have not been seen. The preceding delineation, copied from Druitt, 
gives a good idea of the appearance sometimes presented by this disease 
when situated in the hand. 

For an exceedingly interesting and instructive account of the anatomy, 
physiology, and pathology of these tumours, the reader is referred to 
Professor Paget's valuable Lectures on Tumours, delivered in the Theatre 
of the Royal College of Surgeons of England, during 1851, and pub- 
lished in the "Medical Gazette." 

Ossification is the only change connected with these tumours which 
has been considered as a development. When the process is complete, 
the bone consists of thin cancellous tissue enclosed in a thin compact 
shell or covering. 

The different kinds of degeneration to which cartilaginous tumours 
are liable, are the soft and the fatty ; of which the former is the princi- 
pal : in it, part of the tumour becomes converted into soft or liquid 
matter, which has been found to present great varieties of appearance. 
Mr. Paget thinks, that, although in many instances this substance 
appears to be formed by a liquefaction of the tumour, it may in some be 
a blastema in which the process of development has failed, and that it 
may therefore be a degeneration, or a defect of development. Some 
cartilaginous tumours have been found to contain a pulpy substance of 
a yellow colour, and it has been considered probable that this is the 
result of fatty degeneration. 

These tumours commence more frequently before the period of puberty 
than later in life ; sometimes they are numerous, as may often be ob- 
served in the hands and feet ; the tendency to them has occasionally 

Fie. 237. 




been found to be hereditary ; and although a few cases are recorded in 
which they have been found to return after removal, such instances are 

Fig. 287. Remarkable example of ossification of enchondromatous tumour. From a 
preparation in my collection. 



760 TUMOURS. 

very rare, and it may therefore be stated, as a general rule, that they 
are innocent tumours. 

The preceding figure, taken from a preparation in my collection, 
is a good representation of a cartilaginous tumour on the metacarpal 
bone of the forefinger. 

The finger was removed many years ago, and the patient has ever 
since been perfectly well. 

The conjunction of cartilaginous and medullary tumours is by no 
means unfrequent in some organs. 

When cartilaginous tumours are deep-seated, their diagnosis from 
cancerous tumours is not easy. Professor Bennett in his work on can- 
cerous and cancroid growths makes the following remarks on cartila- 
ginous growths : " When enchondroma occurs in the extremities, and 
especially in the fingers and arms, is connected with the bones, and sur- 
rounded by an osseous capsule, its diagnosis from cancer is exceedingly 
easy. But when it is deep-seated, covered with soft parts, and has no 
distinct bony capsule, its detection is very difficult. It may thus be 
readily confounded with cancer of the bones, of which disease it presents 
all the general symptoms and signs ; and if it be softened, it is not 
easily separated from cancer with the aid of the microscope, even after 
excision." 

Treatment. — The only judicious method of treatment in a case of 
cartilaginous tumour is removal by excision, and that at an early 
period. 

VI. AND VII. CALCAREOUS AND OSSEOUS TUMOURS. 

The occurrence of calcareous and osseous tumours is not unfrequent. 
The former consist of unorganized deposits of calcareous salts, and, 
properly speaking, constitute concretions. These concretions are found 
between various histological elements, and among other situations are 
met with in the parenchyma of organs, as for example, in the testicle, 
in the mammary gland, and in the tonsils. They are also found in 
fibrous tumours, and in other structures of a fibrous character, and not 
unfrequently in the lymphatic glands, more especially in those of the 
neck and face, when they present the characters of a hard tumour, free 
from pain and tenderness, very movable, and for which the proper pro- 
ceeding is excision. 

Osseous tumours are almost always met with in or upon bones. Ex- 
amples, however, have occurred of osseous tumours formed of soft can- 
cellous tissue and medulla, and completely isolated from bones. Among 
other examples of these extremely rare isolated osseous tumours, Mr. 
Paget refers to one in the Museum of the Royal College of Surgeons of 
England, and another in that of St. George's Hospital. The situation 
of the former was over the dorsal surfaces of the trapezial and scaphoid 
bones ; the latter was imbedded in fibro-cellular tissue in front of the 
first metacarpal bone. Both tumours were perfectly isolated from the 
subjacent bones. 

Osseous tumours have been divided into two kinds, the cancellous, and 
the compact or ivory-like : the former resembling the medullary tissue 
of healthy bone, and the latter, its compact walls. The difference in 



TUMOURS. 



761 



the density of the two kinds is ascribed not to any difference in the 
component parts themselves, but in the degree of closeness with which 
they are compacted together. 



Fig. 288. 



Fig. 289. 




Cancellous bony tumours are generally more or less round in form, 
though somewhat smooth upon the surface, more frequently present 
numerous lobes and nodules. They are slow in their growth, but often 
attain a great size. Mr. Paget mentions that the largest he has had an 
opportunity of seeing is in the Museum of the Royal College of Sur- 
geons of England. It surrounds the upper two-thirds of the tibia ; and 
measures a yard in circumference. The largest I have seen is one in 
my own collection, of which the two accompanying figures are good deli- 
neations : — 

It is an immense mass of bone attached to the os innominatum, can- 
cellous in its interior, nodulated on its surface, and covered by a thin 
layer of compact bone. The patient laboured under the disease for ten 
years, and died in .consequence of the sloughing of the soft parts. As 
the osseous tumour was uncombined with other elements, it cannot be 

Fig. 288. Remarkable osseous tumour of os innominatum. Front view. From a 
preparation in my collection. 

Fig. 289. Back view of same preparation. 



762 TUMOURS. 

said to be an example of osteosarcoma, under which appellation many 
include all tumours in which bone is mingled with soft tissue. The 
viscera were perfectly healthy. 

The compact or ivory-like bone tumours are very seldom found except 
in connexion with the bones of the cranium, or in the lower jaw ; more 
rarely in the latter situation than in the former. They sometimes grow 
from the outer table and diploe of the cranium, presenting the appear- 
ance of outgrowths of those parts ; but more frequently originate in 
the tables of the cranial bones, especially in the frontal sinus ; and as 
their growth advances, they press inwards upon the brain, and forwards 
on the eye, as well as outwards. These tumours have also been found 
in other situations, as on the humerus, and on the femur; but such 
instances are extremely rare. In the Museum of the Aberdeen Royal 
Infirmary there is a specimen of a very large tumour on the shaft of 
the femur, which appears to belong to this class. Its surface is uniform, 
and its structure throughout exceedingly hard, the component parts 
being firmly compacted together, and everywhere free from friability. 

Osseous tumours, when uncombined with other elements, are invariably 
non-malignant. 

The bony part of medullary tumours of bone differs from the cancel- 
lous part of osseous tumours, not only in being infiltrated with cancerous 
matter, but also in being more friable. 

II. HETEROLOGOUS, HETEROMORPHOUS, OR MALIGNANT TUMOURS. 
SCROFULOUS OR TUBERCULAR TUMOUR. 

This tumour owes its peculiarity to the presence of a particular de- 
posit, called tubercular exudation, or tubercle. These exudations occur 
most frequently in young subjects from about the third year to the 
adult period ; they are most common during childhood and youth in the 
lymphatic glands, especially the cervical and mesenteric ;. and in adults, 
they are met with much more frequently in the lungs than in other 
parts. They are found in almost all tissues, and are common on serous 
surfaces, in areolar tissue, and, as we have already seen, in the testicle. 
In the common scrofulous affection of the lymphatic glands of the neck, 
and in scrofulous disease of the testicle, we have two examples of tuber- 
cular exudation, which frequently come under the consideration of the 
surgeon. 

Tubercular exudation is of a dirty white, or opaque yellowish colour, 
and of various degrees of consistency, from that of a tough cheese to 
that of a much softer substance. Yogel remarks, " Whenever tubercles 
are observed in what may be presumed to be their earliest stages, they 
appear solid, form a more or less dense mass, and fill up all the inter- 
stices of the elementary tissues in which they are deposited. The tis- 
sues are usually neither displaced nor altered by the tubercular matter ; 
on the contrary, they in general retain their normal position ; they are, 
however, as closely and perfectly invested by it, as the stones of a wall 
by solidified mortar which has been applied between them." 

On microscopic examination, tubercular matter is found to consist of 
minute granules, and imperfectly developed cells, commonly called tu- 



TUMOURS. 763 

bercle-corpuscles. The proportion of the constituents varies in different 
cases. Some of these granules appear to consist chiefly of nitrogenized 
compounds, others of salts of lime, which occasionally, on the absorp- 
tion of the animal matter, remain, constituting calcareous concretions. 
The tubercle-corpuscles are small, irregularly shaped, usually roundish, 
oval, or slightly angular, and contain several granules, but have no dis- 
tinct nucleus. 

As tubercular deposit contains no nucleated or reproductive cells, its 
increase can be effected only by fresh exudation. It may either remain 
without change, or be absorbed, or, by acting as foreign matter, may 
induce irritation and inflammation in surrounding tissues, and becoming 

Fig. 290. Fig. 291. Fig. 292. 




■evo 



$^.@ .-.q o p&y^a- ■■■°-.- 



softened by admixture with inflammatory products, may with them form 
scrofulous abscess, in which the tubercular and purulent matters are 
commingled. Examples of such abscesses are of frequent occurrence. 
According to Engel, Vogel, and others, the causes of softening of tuber- 
cle may be referred partly to influences residing within the tubercular 
mass, and partly to external influences, as extreme moisture, suppura- 
tion in the surrounding tissues, &c. 

Tubercle may result from perversion of nutrition, quite independently 
of the inflammatory process, or from an abnormal degree of vascular 
activity, whether merely congestion, or actual inflammation. When 
exudation of liquor sanguinis has been produced, the change into 
tubercle is believed to depend on the constitution or inherent composi- 
tion of the exudation, which constitution is determined by that of the 
blood ; and this being the case, the importance of attending to the 
nature of the food, of promoting the proper performance of the func- 
tions of the digestive organs, and of guarding against everything cal- 
culated to act unfavourably on the composition and properties of the 
blood, becomes evident. An excellent writer says, "In my opinion 
there is not a shadow of evidence to show, that the deposit of tubercular 
matter is always and necessarily preceded by inflammation. Yet an 
undoubted and most important connexion obtains between the occur- 
rence of inflammation and the occurrence of tubercles. Tubercles will 
cause inflammation, and inflammation will determine the development of 

Fig. 290. Tubercle-corpuscles, &c, from a soft tubercular mass in the lungs. From 
Bennett. 

Fig. 291. Tubercle-corpuscles, &c, with and without acetic acid, from the lung. 

Fig. 292. Tubercle-corpuscles, granules, and debris, from the brain. 



764 TUMOURS. 

tubercles. The enlarging tubercles excite inflammation in the surround- 
ing textures by the pressure they exert upon them, and probably in 
other ways, by mechanically interfering with the circulation of the 
blood, for example ; and the inflammation lit up is usually of the scrofu- 
lous kind ; it is slow, and partial, and easily quieted by treatment, 
though scarcely to be cured. On the other hand, there are numerous 
facts to prove that, in a person having the scrofulous diathesis, the 
occurrence of inflammation within the chest may arouse that previously 
dormant tendency into action, and become the exciting cause of the 
secretion or separation of the tubercular matter from the blood." 

Tubercular exudation occurs exclusively in persons who have the scro- 
fulous diathesis, which is therefore said to predispose to tubercle. This 
diathesis is hereditary, and is met with in persons of all temperaments, 
but is most usual in the sanguine and phlegmatic. The characters 
which indicate its existence in persons of the sanguine temperament are 
light hair, skin fine white, with a transparent brilliancy, allowing 
numerous subcutaneous veins to be seen shining through it ; eyelashes* 
long, silky, and graceful ; iris grey or blue ; eyeball prominent, the 
sclerotic having a shining whiteness or pearly lustre ; the pupils large ; 
the muscles flabby ; the circulation feeble ; the surface of the body 
easily chilled ; and the digestive organs easily deranged. These are the 
principal physical characteristics, and with them are usually associated 
certain moral characters, namely, warm affections, quickness of percep- 
tion, lively imagination, amiability of disposition, and a delicate and 
susceptible cast of mind. When the scrofulous diathesis exists in per- 
sons of a phlegmatic temperament, its principal characteristics are dark 
complexion ; skin thick, pasty, and sallow ; head large ; eyes large and 
prominent ; upper lip, in general, thick ; expression of countenance 
dull and unpleasing ; muscles soft and flabby ; chest narrow ; belly pro- 
tuberant ; circulation feeble ; digestive organs liable to derangement, 
with other symptoms indicating feebleness of constitution. 

The principal known exciting causes of tubercular deposit are, habi- 
tual insufficiency of food ; deficiency of fresh air and exercise ; resi- 
dence in a low, damp situation ; want of free exposure to the light of 
the sun ; debility from excessive evacuations, or other causes ; insuffi- 
cient clothing ; long-continued derangement of the digestive organs, 
and habitual mental depression. Dr. Alison says of the exciting causes 
of this deposit, " They may be ranked together as causes of debility, 
acting permanently or habitually for a length of time, although not so 
powerfully as to produce sudden or violent effects." 

These considerations suggest very strongly, the necessity, in all cases 
where the scrofulous diathesis exists, or when the local manifestation 
has taken place, of generous diet ; living in a dry bracing atmosphere ; 
free exposure to the light of the sun and exercise in the open air ; suit- 
able clothing ; maintaining a healthy condition of the skin by some of 
the different modes of bathing, or by sponging, and friction with a hair 
glove ; the proper regulation of the digestive organs ; and the cultiva- 
tion of habitual cheerfulness. Some medicines, more particularly the 
preparations of iron, of quinine, or of quinine and iron, the syrup of 
the iodide of iron, cod-liver oil, and olive oil, are useful. It should be 



TUMOURS. 765 

kept in view, that as strength can only be acquired by the proper assimi- 
lation of nourishment, one of the most important indications to be ful- 
filled by medicine, is to put the digestive organs into a suitable state for 
the proper performance of their functions ; and the medicine most 
likely to accomplish this desirable purpose should therefore be employed. 
Cod-liver oil is well known to be an invaluable remedy in all scrofulous 
affections, and in none is it more successful than in scrofulous disease of 
the glands of the neck, and scrofulous disease of the testicle. Of the 
beneficial effects of the internal use of olive oil in the same affections I 
am perfectly satisfied, from having used it extensively in these and 
many other scrofulous diseases. In many instances, cream is an effi- 
cient and agreeable substitute for the cod-liver or olive oil. It is well 
known that tubercular deposit is much more under the influence of con- 
stitutional than of local treatment. As to the latter, it seems unne- 
cessary to add anything to what has been already stated regarding the 
local treatment of scrofulous disease of the testicle, except that, when 
the degeneration is in the testis, to an extent which is considered incu- 
rable, the proper proceeding is removal ; whereas, when the disease is 
in the glands of the neck, and when the swelling goes on to suppuration 
instead of subsiding under the suitable constitutional and local treat- 
ment, it is advisable to promote suppuration, as being, next to discus- 
sion, the best means of cure. That the suppuration may be to such an 
extent as to insure complete disintegration of the tubercular deposit, 
which is very important, it is proper to delay the opening until suppu- 
ration be perfectly established, then to open the abscess by means of 
caustic potass, and, if necessary, to insure the complete destruction of 
the infiltrated part by the introduction of the caustic into it ; after 
which, extrusion, granulation, and cicatrization should be promoted by 
the usual means. In many scrofulous affections of the glands in the 
neck, when there is scrofulous deposit, the above will be found the best 
mode of proceeding, when proper constitutional and local treatment has 
been fairly and fully tried, and has failed to produce discussion ; but it 
must also be remembered, that slight suppurations occur in the glands 
of scrofulous persous as well as in those of others, when the best local 
treatment consists in making an early opening with a bistoury or lan- 
cet, as soon as fluctuation is discoverable, and before the tissues have 
become thinned or weakened. This proceeding will prevent the destruc- 
tion of tissue, and the formation of a large cicatrix — unpleasant results 
of the first-mentioned mode of treatment ; but it is chiefly applicable 
to those cases in which suppuration has taken place unconnected with 
tubercular deposit. 

CANCEROUS GROWTHS. 

As all writers have not affixed the same meaning to some terms used 
in the nomenclature of tumours of this class, it may be proper to mention 
that, in the following remarks, the appellations, Cancerous Growths, 
Cancer, and Carcinoma are used synonymously to denote a genus of 
disease of which there are several varieties or species, possessing certain 
principal characters in common, but having each at the same time some 
distinguishing peculiarities. 



766 



TUMOURS. 



- Of these varieties the four following are readily recognised : Car- 
cinoma simplex, or Hard Cancer; Carcinoma medullare, or Soft Cancer; 
Carcinoma alveolare, or Colloid Cancer ; and Carcinoma melanodes, or 
Black Cancer. 



I. CARCINOMA SIMPLEX. 

Synonyms.— Carcinoma, Carcinoma simplex, Carcinoma scirrhosum, 
Scirrhus, Scirrhoma, Scirrhosis, Stone and Hard Cancer, are some of 
the appellations given to this variety. 

Common Characters. — Hardness is a distinguishing peculiarity of this 
variety ; it is firm and incompressible ; at an early stage it is freely 
movable, but subsequently becomes firmly attached to the skin and sub- 
jacent parts ; its surface is nodulated ; the veins superficial to it become, 
at an advanced period of its growth, tortuous and enlarged ; at its com- 
mencement it may be attended with little or no pain, so that considera- 
ble progress may have been made before the discovery of its presence ; 
but ultimately it is accompanied by acute pain of a lancinating character. 



Fig. 293. 



Fig. 294. 









Fig. 296. 



Fig. 295. 



After removal it creaks, when cut with a sharp knife ; a thin lamina is 
pellucid, but in the mass it is white, with a bluish tinge ; it is seen to 
consist of two distinct substances, one of a comparatively soft con- 
sistency, of a satiny appearance, and a bluish-white colour ; the other 



Fig. 293. Portion of the section from a carcinomatous tumour of the breast ; consist- 
ing of fibrous tissue and cysts, enclosing cancer-cells and granules. A compound 
granular corpuscle is also visible. 

Fig. 294. Another portion of the same section treated with acetic acid. The fibrous 
tissue is rendered more transparent, and elongated nuclei are visible scattered through 
it. The nuclei of the cancer-cells are unchanged, while their walls are transparent. A 
compound granular corpuscle is seen at the upper part of the figure. 

Fig. 295. Cancer-cells from the cream-like juice squeezed from the tumour. Nu- 
merous granules, and a compound granular cell are seen. 

Fig. 296. The same after the addition of acetic acid. — From Bennett. 



TUMOURS. 767 

and larger, of an opaque white appearance, of a paler colour than the 
soft part, and consisting of numerous interlacing bands ; it is heavy in 
proportion to its bulk, and unctuous to the touch: by pressure or 
scraping it yields a small quantity of cancerous juice, which, at an early 
stage, has the appearance of a clear transparent liquid, and afterwards 
of a white creamy fluid ; it is not furnished with a capsule ; does not 
present a distinctly defined border ; and is irregularly blended with the 
surrounding parts. 

Microscopic Characters. — When examined by the aid of the micro- 
scope, carcinoma simplex is found to consist of a fibrous matrix, so 
arranged as to form numerous cysts, in which, as well as between the 
meshes of the fibres, numerous cells are observed. These cells are 
highly developed, the walls being, in young cells, distended and smooth, 
and in old cells, flaccid and corrugated. In size they are variable, and 
in form they may be oval, caudate, round, spindle-shaped, oblong, heart- 
shaped, or of various indescribable forms depending on lateral pressure; 
and this diversity is their most distinguishing character in respect to 
form. Each cell contains one, two, or more nuclei with enclosed 
nucleoli ; and frequently there is an appearance of cells within cells. 
The liquid contents of the cell-wall are at first transparent and colour- 
less, but afterwards become opaque from the formation of granules and 
molecules. Water penetrates the wall by endosmosis, distending and 
raising it up. Acetic acid exercises its usual effect on it, dissolving it, 
and thereby making the nuclei more conspicuous. The fluid or juice 

Fig. 297. Fig. 298. Fig. 299. 




which can be scraped or pressed from a cut surface of the tumour is 
found to contain numerous cancer cells. 

II. CARCINOMA MEDULLARE. 

Synonyms. — Among the many names given to this variety are, Car- 
cinoma medullare, Medullary Fungus, Fungus nematodes, Medullary 
Sarcoma, Medullary Cancer, Cephaloma, Encephaloma, Fungoid Disease, 
and Encephaloid, or Soft Cancer. 

Common and Microscopic Characters. — This variety generally occurs 
at a much earlier period of life than the former ; the tumour is less cir- 
cumscribed, and its increase much more rapid ; it is for a considerable 

Fig. 297. Dense fibrous and elastic tissue, in which cancer-cells are infiltrated from 
cancer of rectum. 

Fig. 298. Cancer-cells scraped from the surface, in the same case. 
Fig. 299. The same after the addition of acetic acid. — From Bennett. 



768 



TUMOURS. 



time attended with little or no pain, nor does manipulation produce any 
uneasy sensation ; on palpation it presents a peculiar elastic feeling, 
which has sometimes by inexperienced observers been mistaken for 
fluctuation ; the veins over it become congested ; the skin retains for a 
considerable time its natural appearance, but changes in colour as the 
disease advances, presenting a dingy bluish tint ; it becomes tense and 
painful, and by and by ulcerates ; a bloody fluid is evacuated, which 
soon assumes a foetid character ; a fungoid growth soon protrudes, pre- 
senting the appearance of an irregular surface of unhealthy granula- 
tions ; the tumour comes to be attended with pain of a dull, heavy, 
sickening character ; the fungus has a great tendency to bleed ; the 
tumour increases very rapidly, affecting not only the surrounding parts, 
but also the neighbouring lymphatics and glands ; and death soon takes 



Fig 800. 










• : '^;/.i^W 



%''.'<: 



•=;.'::•■ 



":M/ 
mi 



u&r\, 



'm 



■'■■m 



Fig. 301 




?! 



place in consequence of repeated bleeding, invasion of internal organs, 
cancerous cachexy, or, of gangrene of the upper extremity, as I saw 
very lately in a case of this disease in the breast, in which the gland 
and axilla presented one diseased mass. 



Fig. 303. 



Fig. 304. Fig. 305. 



Fig. 306. 



Fig. 307. 



ilSl 



'§£M0mM 



0sm 

HP 



■■$ 



§ 



The tumour on being cut into is seen to consist in a great measure of 
a soft, white, opaque, pulpy substance, resembling in colour and consis- 
tency that of healthy brain, traversed with fibrous septa, which, however, 



Figs. 300, 301. Older cancer-cells before and after the addition of acetic acid. 
Fig. 302. Advanced cancer-cells, including secondary cells. 

Figs. 303, 304, 305. Cancer-cells before and after the addition of acetic acid, also 
the structure of the reticulatum from encephaloma of the testicle. 

Figs. 306, 307. Young cancer-cells before and after the addition of acetic acid. 



TUMOURS. 



'69 



are much fewer and thinner than in carcinoma simplex, resembling those 
of carcinoma simplex in the denser part of the tumour, but in the pulpy 
and broken-down portions, presenting only very slight traces. Extra- 
vasations of blood give to the cut portion, at some places, a reddish ap- 
pearance, constituting what has been called by some, fungus nematodes. 

The cells are more numerous than in the first variety, and more highly 
developed ; and the cream-like fluid, when examined with the aid of the 
microscope, is seen to abound with cancer-cells in a high degree of 
development. In this form of carcinoma there is often observed a 
yellowish-coloured paste, sometimes reticulated, and sometimes collected 
into masses. This has been attributed to fatty degeneration of can- 
cerous cells, and is described by Professor Muller as " cancer reticulare." 

This variety of carcinoma differs from the former chiefly in density. 



III. CARCINOMA ALVEOLARE. 



Synonyms. — Carcinoma alveolare is sometimes called Colloid (from 
xoXXa, glue), and also Gelatiniform cancer. 

It is comparatively rare, and is met with principally in the stomach 
and omentum ; it is found to consist of fibres, so as to form loculi or 
areolae, varying in size, and containing a soft viscous matter, sometimes 



Fig. 308. 



Fig. 309. 



Fig. 310. 




Fig. 311. 



gray or amber-coloured, sometimes opalescent, or opaque, or of a green- 
ish yellow colour. In this substance are found numerous nucleated cells, 
having the usual characters of cancer-cells. The accompanying figures, 
for which I am indebted to Professor Bennett, give a delineation of this 
form of cancer. 



Figs. 308, 309, 310, 311. Structure of colloid cancer before and after the addition of 
acetic acid. 

49 




770 TUMOURS. 



IV. CARCINOMA MELANODES, OR BLACK CANCER. 

This tumour occurs much more frequently in the lower animals, espe- 
cially in the horse, than in man ; but in man the malignant character 

is more marked. Its most common 
Fi S- 312 - primary seats are, the eye, the cellu- 

lar tissue, and more especially the 
subcutaneous tissue, and that con- 
nected with the serous membranes. 
Sometimes it occurs as a distinct tu- 
mour with a fibrous stroma highly 
vascular, and with the colouring mat- 
ter, which is non-vascular, diffused 
through it. When the colouring mat- 
ter is viewed by the aid of the micro- 
scope, it is found to consist of minute 
granules, angular in form, and of a 
black, or brownish black colour. 
It is frequently found associated with other morbid structures, espe- 
cially with carcinoma medullare. It is attended with cachexia, has the 
power of invading surrounding structures, and assimilating them to itself, 
and shows the same progress as other malignant tumours ; and when 
the diathesis is established, the lungs, liver, bones, or other organs may 
be invaded. 

ORIGIN, PROGRESS, AND TREATMENT OF CANCEROUS GROWTHS. 

When exudation of liquor sanguinis has taken place, and has become 
coagulated, it presents, at the earliest period at which it has been ex- 
amined, a finely molecular and granular appearance. This substance 
constitutes a blastema, in which the cancer-cells arise. The change of the 
exudation into cancer is believed to depend on the constitution or in- 
herent composition of the exudation, which constitution is determined by 
that of the blood. Fibrous tissue, cancer-cells, and nuclei having been 
produced, the cancer-cells propagate themselves, the old cell-walls give 
way, liberating the young cells or nuclei, which in their turn give rise 
to others. Fresh materials for assimilation are afforded to the tumour 
by exudation from new vessels developed in it ; although just at the 
commencement of the disease, the exudation which constitutes the blas- 
tema, takes place from the old vessels. The tumour thus possesses the 
property of growth and reproduction, and in that respect cancer differs 
from tubercle, which can only increase by fresh exudation, and new 
development of tubercular matter in the exudation, as tubercle does not 
contain nucleated or reproductive cells. 

There seems reason to believe that a cancerous tumour, after passing 
through its usual stage of growth, may degenerate or be transformed 
into fibrous cicatrix, by the absorption of its softer parts and the con- 
traction of its fibrous stroma ; or into a fatty mass, by the deposition of 

Fig. 312. Melanic cancer of the cheek. Cells more or less loaded with black pigment. 
— Bennett. 



i 



TUMOURS. 771 

fat granules between the cell-walls and the nuclei, rendering the cancer 
cells abortive ; or into a calcareous concretion by the absorption of the 
animal matter and the accumulation of the earthy salts of the exudation. 
But although these different forms of degeneration may have taken 
place in a very small number of instances, they are of so extremely 
rare occurrence, that no one thinks of looking for a spontaneous cure of 
cancer ; on the contrary, it is found that the nature of the disease 
is to progress, and to conduct to death in some of the ways already 
mentioned. 

The various forms of carcinoma appear to differ from each other prin- 
cipally in density, but to have all the same origin, the same progress, 
and the same result. 

In regard to the treatment of cancer, one of the best authorities has 
said, — " The practical rule, which pathology and experience unite in 
causing us to adopt, seems to be this : that so long as a cancer remains 
fixed in a part which is capable of being removed, and the strength 
of the patient is not too much reduced, so long is the surgeon war- 
ranted to interfere." Removal by excision is the advisable proceeding. 
If part of an organ be affected, the whole of the organ must be removed. 
In all cases, not only the whole of the tumour itself must be removed, 
but also a considerable portion of the surrounding tissue, lest cancer 
cells should have been infiltrated in the apparently healthy tissue: 
these, if allowed to remain, would insure a return of the disease. In 
every instance, therefore, the surrounding tissue should be removed to 
a considerable extent along with the tumour ; for, although it must be 
allowed that in very many cases, even with this precaution, the disease 
returns : without it, its return may be said to be a certainty. It is 
equally important to resort to early excision, before the lymphatics have 
been invaded. Operative interference after the occurrence of lymphatic 
invasion could only bring discredit upon surgery, by subjecting the patient 
to a useless operation, followed by a return of the tumour ; and, in all 
probability, in a form marked by increased rapidity of growth. The 
proper proceeding may, therefore, be said to consist in early and free 
excision. When the whole of the diseased part, together with some of 
the surrounding tissue, cannot be removed, or when the period of 
lymphatic invasion has arrived, the surgeon should then restrict his in- 
terference to endeavours to palliate the disease which he cannot cure, 
and to diminish the urgency of distressing symptoms as they occur in 
its progress. 

Of late years, the chloride of zinc has been much used as an escha- 
rotic in the treatment of some cancerous affections ; and there can be 
no doubt that, in some instances, it is an admirable application, and 
that its use accomplishes all that can be desired. It is made into a 
paste, by the addition of a very small quantity of water to render it 
liquid, and of as much flour as may be necessary to give it consistency. 
The length of time during which the paste should be applied, varies ac- 
cording to the depth of the part to be destroyed ; but it may be stated 
generally to be from ten or twelve minutes to nearly half an hour. 
Poultices must afterwards be applied to promote the separation of the 



772 TUMOURS. 

slough, and the part afterwards treated as the common principles of 
surgery suggest. 

The cases for which this method of treatment is suitable are, those in 
which the disease presents a considerable extent of surface compared 
with its depth ; — cases in which, though removal is desirable, excision 
so generally preferable would, from some circumstance, be hazardous ; 
and cases of comparatively superficial cancerous or cancroid affections 
in patients who will not submit to operation. The use of this escharotic 
has been justly regarded as a valuable addition to the resources of the 
practical surgeon. 



773 



CHAPTER XXV. 

AFFECTIONS OF THE BREAST. 

MAMMITIS. 

« 

Mammitis, and mazoitis (from M-afe the breast) are names given to 
inflammation of the breast, which may be either acute or chronic. 

ACUTE INFLAMMATION OP THE BREAST. 

This is a disease of very rare occurrence, except during the period of 
lactation, the active state of the gland then rendering it very susceptible 
of influences causing inflammation. These exciting causes may be general 
or local. To the former class belong irregularities of diet, cold, mental 
emotions, or any circumstance calculated to produce a decided impression 
on the system ; and to the latter, contusions, external injury, the direct 
application of cold, and too long retention of milk. 

The local symptoms are those usual in inflammation of a very aggra- 
vated form, together with diminished secretion of part of the gland, and 
suspended secretion, if the whole of the gland be inflamed. When the 
inflammation is very acute, resolution is rarely obtained, unless the treat- 
ment be early and energetic ; and the result most apt to take place is 
suppuration, the matter forming an abscess called a milk abscess in the 
breast. 

The constitutional disturbance is great, and usually commences with 
a rigour. 

The object aimed at by treatment in the first instance, should be to 
obtain resolution. With this view all exciting causes should be remov- 
ed ; saline purgatives and antimonials prescribed, and the effect of the 
latter kept up ; the diet restricted, and of an unstimulating nature. With 
regard to local treatment, support of the breast by means of a handker- 
chief, leeches, and fomentations, simple or anodyne, are the best reme- 
dies in the early stage ; but if, instead of resolution, suppuration take 
place, early, free, and direct incision should be resorted to. By making 
an early, free, and direct opening, sinuses are prevented, much suffering 
is spared, and pressure for the purpose of evacuating the matter, which 
is not only painful but highly injurious, is rendered unnecessary. Warm 
fomentations and tepid water-dressings, or small poultices, are necessary 
for a short time ; but all relaxing applications should be laid aside as 
early as possible, and gentle support afforded by means of strapping or 
gentle bandaging, and a change made to a more generous diet ; — for in 
this, as in many other affections, recovery is sure to be delayed by the 



774 AFFECTIONS OF THE BREAST. 

long continuance of relaxing applications, or restriction to a diet not 
sufficiently strengthening. 

CHRONIC INFLAMMATION OF THE BREAST. 

The mamma is not unfrequently affected with a slight grade of the 
inflammatory process, which although attended with little pain often 
persists for a long time, and gives rise to enlargement and induration of 
the breast. This condition is usually symptomatic of some derangement 
of the menstrual or intestinal secretions, and is most common in females 
about the middle period of life, who are unmarried or have not had chil- 
dren. Swelling and slight induration are the principal symptoms, and 
they generally affect the whole, but in some instances only a part of the 
gland. There is little pain or tenderness. The swelling is less heavy 
than that of a genuine tumour, and usually more diffused. These 
symptoms, andlhe absence of the signs of the usual tumours of the breast, 
together with the readiness with which it yields to treatment, are the 
characteristic marks of this affection. 

From what has been already mentioned it will be readily understood, 
that the proper proceeding in these cases consists mainly of constitu- 
tional treatment, the aim of which should be to promote a healthy con- 
dition of the menstrual and intestinal secretions, and to improve the 
general health and strength : from the fulfilment of these indications the 
greatest benefit is found to accrue. The local treatment consists princi- 
pally in the use of some of the various discutient applications, and in 
the judicious employment of slight support and pressure by means of 
strapping or bandaging, chiefly of strapping. The effects of strapping 
must be carefully watched ; but from its cautious use, together with 
suitable constitutional treatment, the most gratifying results are often 
obtained. Should the pain be at any time very acute, a few leeches and 
fomentations may also be employed. 

CHRONIC ABSCESS IN THE BREAST. 

The symptoms of this affection are a swelling, unattended with pain 
or tenderness, deep-seated, and generally about the size of an egg ; the 
absence of any redness, heat, or swelling of the skin ; and in the rest 
of the gland, the usual characters as to size and consistence. 

This disease has been mistaken for tumour. The best means for 
arriving at a correct diagnosis are, the presence of the symptoms men- 
tioned above ; the equality of surface of the swelling ; the feeling, more 
or less distinct, of fluctuation on careful examination ; and the absence 
of the usual characters of the tumours of the breast. When the diag- 
nosis is still doubtful, it can be made out by means of the exploring 
needle or a small puncture: 'the matter is contained in a firm cyst 
situated sometimes in the substance of the gland, but more frequently 
between it and the subjacent muscles. A dependent free opening is 
necessary ; the wound must be kept open, and treatment adopted, 
according to the common principles of surgery, for promoting the filling 
up of the cavity. 






AFFECTIONS OF THE BREAST. 775 



IRRITABLE MAMMA, OR NEURALGIA OF THE BREAST. 

This distressing affection is most frequently met with in persons from 
fifteen to thirty years of age. It does not seem to be confined to any 
temperament ; I have often met with it in females of sanguine tempera- 
ment, and often in pale cachectic females of nervous disposition, who 
have suffered from grief and mental anxiety. 

In most cases pain is almost constantly felt, but with different degrees 
of intensity ; so that the patient has remissions, rather than complete 
intermissions of pain. The pain is liable to great exacerbations, some 
of which are periodical, as for example, before the menstrual period, 
when it is often described by patients as being most excruciating. It 
is often excited also at other times by mental anxiety, and, judging from 
my own observation, I should say, by any cause, mental or bodily, by 
which a depressing effect is produced on the system. It is usually dimi- 
nished during the menstrual period. 

Tenderness on pressure is another symptom, and is in some cases so 
great that the slightest touch, and even the pressure" of the dress causes 
great pain. 

In many instances these symptoms are unattended with any enlarge- 
ment; occasionally, however, there is slight enlargement, but very 
rarely any alteration of structure ; yet sometimes there is the appear- 
ance of increased density, in some parts of the gland. 

This neuralgic affection is, in the great majority of cases, regarded 
as symptomatic of painful or deficient menstruation ; in some instances, 
of derangement of the digestive organs ; and in others, of weakness 
occasioned by continued grief, mental anxiety, or other causes. 

Some alleviation in this most distressing affection is sometimes expe- 
rienced from the use of warm and opiate fomentations ; from anodyne 
applications composed of preparations of conium, opium, belladonna, or 
aconite ; or of combinations of these remedies, in the forms of liniment, 
ointment, or plaster. But, however necessary may be the employment 
of some local remedies as palliatives, the principal part of the treat- 
ment, and that on which alone dependence can be placed for effecting a 
cure, is the constitutional treatment, comprehending the use of such 
remedies as are calculated to promote the proper condition of the ute- 
rine and intestinal secretions, and to improve the general health and 
strength. A complete change of scene, air, and mental occupation has 
often been found to remove the complaint. The practitioner, remem- 
bering what are the indications to be fulfilled, will select for their 
accomplishment the means most suitable in the particular circumstances 
of each case. 

MAMMARY GLANDULAR TUMOUR. 

Synonyms. — This affection is called by Sir A. Cooper the chronic 
mammary tumour ; by Mr. Abernethy the pancreatic tumour ; by Cru- 
veilhier the fibrous tumour of the breast, by Professor Paget the mam- 
mary glandular tumour ; by some writers simple sarcoma ; and by others 
simple tumour. 

These tumours are most common in young women who are unmarried, 



776 



AFFECTIONS OF THE BREAST. 



or who have had no children : they are very seldom found to begin after 
the age of thirty years. Their origin is believed to be connected with 
deficiency or irregularity of the menstrual discharge ; and a remarkable 
fact in regard to them is, that they occasionally disappear ; and, accord- 
ing to a greatly respected authority, they are more likely to do so, if 
any imperfection of the uterine or ovarian functions, in which they 
seem to have their origin, be repaired by marriage, pregnancy, or lac- 
tation. 

The tumour is exceedingly movable, and though furnished with a 
cyst, is diffused into the surrounding tissue to a considerable extent. 
Its form is usually oval, its surface lobulated, it has no elastic or firm 
feeling ; its seat may be upon, within, or in some rare instances, under- 



Fig. 313. 



Fig. 314. 



Fig. 315. 




neath the gland ; it is most usually found near the upper margin of the 
gland, slightly imbedded beneath its surface. In most instances there 
is no accompanying pain ; in some, there is uneasiness not amounting 
to pain ; and in others, very great pain. These tumours are sometimes 
very rapid, but more frequently slow in their growth ; sometimes their 
growth appears to be arrested so that they become stationary ; and in 
a few instances, as has been already mentioned, they have been known 
entirely to disappear. They are formed of hypertrophy or alteration 
of the natural elements, and by the aid of the microscope, these ele- 
ments in a more or less modified form may be recognised. By the 
kindness of Professor Bennett I am allowed the use of the above 
wood-cuts. 

These tumours are innocent in their nature, and very rarely attain to 

Figs. 313, 314, 315. This series of diagrams represents microscopic sections 
of a simple tumour removed by operation from the female breast ; consisting mainly of 
hypertrophy of the fibrous structure of the gland, with enlargement of the included 
ducts and their epithelial linings, c. Section of the epithelium from one of the tubes. 
b. Group of epithelial cells from the same. a. The same after the addition of acetic 
acid. — Bennett. 



AFFECTIONS OF THE BREAST. 777 

any great size ; but as they may grow larger and give rise to anxiety 
in the mind of the patient, they should be removed by excision, which 
can be done with great ease and with the certainty of a satisfactory 
result, as they are not of a malignant character. 

SERO-CYSTIC TUMOUR. 

The following are three different modes of the formation of cysts: — 

1. Some cysts are formed by dilatation and growth of the lactiferous 
tubes. A cyst formed in this way may be emptied through the nipple, 
and as was pointed out by Sir Benjamin Brodie, a bristle may in some 
cases be sent through one of the ducts into the cyst. The cyst is slow 
in its growth, rarely attains very large dimensions, and in the majority 
of cases is unattended with pain ; but in some, patients experience a 
darting pain, or stinging, especially on manipulation, and about the 
menstrual period. In most cases, however, the disease gives rise to no 
inconvenience, except the anxiety caused by the presence of any kind 
of tumour in the breast. The health is not impaired. The skin retains 
its natural colour. The axillary glands do not become affected : and 
on manipulation at an advanced period, fluctuation reveals the exist- 
ence of a fluid, but at an early stage, the tumour has rather a solid 
feeling. The cyst has a covering of fibro-cellular tissue, is lined with 
epithelium, and may contain milk, or a fluid containing epithelial scales, 
or fatty matter, but most commonly serous fluid, which sometimes 
exudes from the nipple. The fluid may be clear, green, reddish, or 
variously tinged. It is extremely unusual for this disease to begin after 
the fiftieth year. 

2. Another mode of formation of cysts is by enlargement and fusion 
of spaces of the fibro-cellular tissue. Effusion takes place into the 
spaces, and the fibro-cellular tissue becomes expanded and condensed 
into a cyst. 

3. It is probable that, in many instances, cysts in the mammary 
gland are formed by the enormous growth of new-formed elementary 
structures, having the character of cells or nuclei, which pursue a 
morbid course from their origin, or from a very early period of their 
development. 

These three modes of the formation of cysts have been briefly described, 
as formation by dilatation and growth of parts of ducts, by enlargement 
of natural spaces, and by development or growth of new-formed nuclei 
or cells. Those cysts, the contents of which are liquid, are called barren; 
and those which have the power of forming more highly organized contents 
are called proliferous. The contents of proliferous cysts vary very much 
in different parts of the body, but in the breast they consist of glandular 
or other vascular growths, which spring from their walls, constituting 
with their cysts the cysto-sarcomata of Sir Benjamin Brodie. These 
intra-cystic mammary growths increase more rapidly than their cysts, 
and at length, excluding the fluid, fill the cysts ; in many cases, they 
coalesce entirely with the cyst walls, and in others, projecting through 
them and growing rapidly, they advance to the integument ; and some- 
times even make their way through it. These growths also exhibit 
great varieties with regard to colour, vascularity, and density. They 



778 



AFFECTIONS OF THE BREAST. 



are found in women of all ages from the period of puberty to the cessa- 
tion of menstruation : and although they may coexist with cancerous 

Fig. 316. 




growths, they are perfectly free from anything of a malignant cha- 
racter. 

In the case of a single cyst, a successful result has been obtained by 
making an incision for the escape of the fluid, or evacuating it by means 
of a small trocar, and afterwards employing the ordinary means for 
promoting the obliteration of the cyst by adhesion or granulation ; but 
excision of the whole of the diseased part is the only certain means of 
cure ; and when there are more cysts than one, the proper proceeding 
is ablation of the breast, and as the disease is not malignant, there is 
every prospect of a satisfactory result, if the whole be removed. 

TRUE HYDATID CYSTS IN THE MAMMA. 

This is an extremely rare form of breast-disease, and consists of a 
parent cyst, containing living entozoa. Within the parent cyst are 
secondary cysts, which consist of parasitic animalcules, named echino- 
coccus hominis, floating in a limpid fluid. This form of disease is met 
with between the ages of twenty-one and fifty years, chiefly in married 
women who have enjoyed good health, to which the development of the 
tumour has not been observed to cause any interruption. The tumour 
is for the most part globular or oval in form ; varies in size from an 
inch to several inches in diameter ; and has been found in different 
parts of the gland. The tumour becomes prominent at its middle, is 
hard at first and incompressible, but by and by becomes lobulated with 
obscure fluctuation, and ultimately fluctuation becomes uncommonly 
distinct. In some cases there is no pain ; in some there is uneasiness ; 
but in others the pain is very great. 

Excision is the proper treatment, and if the cyst be removed, a perfect 
cure is the result. 



Besides the tumours mentioned in this chapter, the mamma is also 
liable to become the seat of fatty, fibrous, fibro-serous, cartilaginous, or 

Fig. 316. From Druitt. 






AFFECTIONS OF THE BREAST. 779 

carcinomatous tumours. For information on these tumours the reader 
is referred to the preceding chapter, in which their characters, pro- 
gress, and treatment, have been described. 

EXCISION OF THE MAMMA. 

The patient having been placed in the recumbent posture, with the 
arm raised, extended, and committed to an assistant to maintain it in 
that position, the surgeon introduces the knife on the axillary aspect of 
the mamma, on a line with the mammilla, and directs it quickly and 
boldly to the opposite point, forming a semielliptical incision along the 
lower aspect of the tumour ; the lower incision being first made that its 
course may not be obscured by blood. A semielliptical incision is then 
made along the upper aspect between the same points of entrance and 
exit. The knife being next carried in a sloping direction, the dissec- 
tion is conducted boldly and promptly from the axillary aspect of the 
wound, in order that by the early division of the principal trunks hemor- 
rhage may in the subsequent parts of the dissection be as much as 
possible prevented. The extent of parts to be removed must vary 
to a certain degree, according to the laxity of the integument, but 
chiefly according to the size and nature of the tumour, it being neces- 
sary, as has been already stated, to remove a considerable portion of 
apparently sound tissue, if there be reason to fear that the tumour is 
not of an innocent character. 

Hemorrhage having been arrested, the edges are brought together, 
and the parts treated according to the approved principles for such 
wounds. 



INDEX 



Abdomen, wounds of, 507 
Abdominal herniae, 450 
Abscess, acute, 47 

acute, condition of parts in, 48 
acute, symptoms, 47 
acute, treatment, 481 
chronic, 49 

chronic, condition of parts in, 49 
chronic, treatment, 50 
Adhesion, 44, 73 
Albugo, 667 
Amaurosis, 691 

Amputation at ankle joint, 622 
at hip joint, 627 
of penis, 628 
at shoulder joint, 617 
Amputations, 608 

of arm, 616 
of fingers, 610 
of forearm, 615 
of foot, 620 
of leg, 624 
of thigh, 625 
of toes, 619 

of under extremity, 619 
of upper extremity, 610 
Anchylosis, 356 
Aneurism, 410 

false, 433 

fatal terminations of, 416 
spontaneous cure of, 421 
symptoms, 419 
treatment, 422 
true, 411 

modes of formation, 41] 
true, varieties of, 413 
varicose, 435 
Aneurisms, divisions of, 410 
Aneurismal varix, 433 
Antrum, affections of, 719 
Arteries, degenerations of, 405 

calcareous degeneration of, 400 
cartilaginous degeneration of, 405 
steatomatous degeneration of, 406 
deligation of, 634 
diseases of, 400 
Arteritis, acute fibrinous, 400 

acute suppurative, 402 
chronic, 405 
limited, 403 
Balanitis, 585 
Bladder, inflammation, acute, of, 586 

inflammation, chronic, of, 587 
Bone, absorption of, 297 
death of, 306 
suppuration in, 292 



Bone, suppuration, acute external, 292 
chronic external, 293 
internal, 293 

internal diffuse acute, 293 
internal limiied, 294 
internal chronic, 295 
scrofulous, 296 
ulceration of, 298 
I Brain, compression of,'220 

concussion of, 213 
! Bronchotomy, 733 
[ Burns, 105 
I Calculi, urinary, 520 
I Calculous disorders, 514 
Calculus in bladder, symptoms of, 534 
treatment of, 538 
in the kidney, 520 
Cancer, 765 

of lip, 720 
Carcinoma alveolare, 769 
medullare, 767 
melanodes, 770 
origin of, 770 
progress of, 770 
simplex, 766 
treatment of, 770 
Caries, 300 
Cartilage, articular, destruction of, 337 

•disease of, 337 
Cataract, 682 

operations for, 684 
Catarrhus vesicae, 587 
Catheterism, 593 
Choroiditis, 674 
Cicatrisation, 52 
Club foot, 382 
Compression of brain, 220 
Concussion of brain, 213 
Conjunctivitis, 651 

catarrhal, 659 
purulent, 660 
pustular, 658 
simple, 657 
strumous, 663 
Cornea, affections of, 664 
conical, 670 
hernia of, 669 
opacities of, 666 
ulcers of, 667 
Corneitis, acute, 665 

scrofulous, 664 
Curvatures of spine, 359 
Curvature, angular, 359 

excurvation, 370 
incurvation, 373 
lateral, 373 



782 



INDEX. 



Curvatures, mixed, 381 
Cystitis, 586 

chronic, 587 
Dacryocystitis acuta, 705 

chronica, 706 
Deligation of arteries, 634 
axillary, 640 
dorsal artery of foot, 648 
common carotid, 637 
common femoral, 644 
superficial femoral, 644 
humeral, 641 
common iliae, 644 
external iliac, 643 
internal iliac, 644 
popliteal, 646, 
radial, 642 
subclavian, 639 
a?nterior tibial, 646 
posterior tibial, 647 
ulnar, 642 
Diathesis, lithic, 514 
oxalic, 518 
phosphatic, 516 
Dislocations, 228 

general doctrines of, 228 
compound, 235 
of ankle joint, 279 

ankle, compound, 283 
clavicle, 240 
elbow joint, 256 
hip joint, 266 
knee joint, 277 
lower jaw, 237 
patella, 277 

radio-ulnar articulations, 261 
shoulder joint, 243 
temporo- maxillary articula- 
tion, 237 
thumb, 264 
wrist-joint, 263 
Distichiasis, 702 
Ectropium, 703 
Effusion of serum, 44 
Emphysema, general, 195 

interlobular, 196 
Enchondroma, 758 
Entropium, 703 
Epiphora, 704 
Equinia, 101 
Erysipelas, 63 

bilious, 67 
definition of, 63 
erratic, 68 
divisions of, 63 
cedematous, 67 
periodic, 68 
phlegmonous, 66 
simple, 64 
treatment of, 68 
Erythema, 62 

fugax, 63 
general, 63 
laeve, 63 
marginatum, 63 
nodosum, 63 
papulatum, 63 
tuberculatum, 63 
Exostosis, 321 

Exudation of coagulable lymph, 44 
Eye, affections of, 657 

extirpation of, 694 
Eyelids, affections of, 700 



Farcy, 101 

Fimbriated synovial membrane, 336 
Fissures around anus, 653 
Fistula in ano, 649 

lachrymalis, 708 
Forceps, spring, 634 
Fractures, 126 

of clavicle, 150 
of cranium, 202 
of the face, 225 
of femur, 155 
of forearm, 129 
general doctrines of, 126 
of humerus, 140 
of leg, 183 

mode of union of, 126 
of patella, 177 
of pelvis, 198 
of ribs, 193 

ofribs, complications of, 195 
of scapula, 146 
special, 129 
of spine, 198 
of sternum, 197 
Fragilitas ossium, 321 
Gangrene, 59. 

local changes in, 60 
symptoms of, 59 
constitutional symptoms of, 61 
Genito-urinary organs, affections of, 578 
Glanders, 101 
Glaucoma, 690 
Gonorrhoea, 578 

external, 585 
praeputialis, 585 
simple, 578 
spurious, 585 
venereal, 579 
in women, 584 
ophthalmia, 663 
Grando, 701 
Granulation, 52, 73 
Haemathorax, 197 
Harelip, 723 
Head, injuries of, 202 
Hemorrhoids, 651 

external, 651 
internal, 652 
Hernia, 450 

femoral, 493 
infantile, 493 
inguinal, 478 

congenital, 490 

encysted, 492 
direct, 488 
oblique, 485 
irreducible, 455 
operation for, 467 
reducible, 450 
strangulated, 462 

operation for, 467 
by diverticulum, 503 
stricture, extraperitoneal division of. 

470 
stricture, intraperitoneal division of. 

470 
treatment, after operation, 477 
umbilical, 501 

in adults, 503 
of children, 502 
congenital, 501 
ventral, 503 
Hordeolum, 700 



INDEX. 



783 



Hydrocele, 572 

of cord, 576 
encysted, of testis, 575 
of tunica vaginalis, 575 
Hydrops articuli, 331 
Incrustation, 74 
Inflammation, 33 

local changes in, 41 
results of, 43 

symptoms, constitutional, 39 
local, 33 
Inflammatory appearances of blood, 40 

fever, 39 
Iris, prolapse of, 669 
Iritis, 676 

acute, 676 
arthritic, 679 
chronic, 678 
rheumatic, 678 
scrofulous, 681 
syphilitic, 680 
traumatic, 678 
Irritable mamma, 775 

testis, 565 
Joints, diseases of, 324 

scrofulous of, 345 
resections of, 630 
Lachrymal apparatus, affections of, 704 

sac, inflammation of, 705 
Laryngotomy, 733 
Leucoma, 667 
Lip, cancer of, 720 
Lips, restoration of, 725 
Lipoma of nose, 710 
Lithic diathesis, 514 
Lithotomy, 539 

history of, 545 
Lithotripsy, 557 
Lithotrity, 556 

Mamma, chronic abscess of, 774 
cystic tumour of, 777 
excision of, 779 
glandular tumour of, 775 
hydatid tumour of, 778 
irritable, 775 
Mammitis, acute, 773 
chronic, 774 
Milium, 701 
Modelling process, 74 
Mollities ossium, 320 
Morbus coxarius, 349 
Nasal duct, obstruction of, 708 
Nebula, 666 
Necrosis, 306 
Neuralgia periostei, 289 

testis, 566 
Nose, affections of, 710 
lipoma of, 710 
polypus of, 712 
Ophthalmia, 657 

catarrho-rheumatic, 674 
gonorrhceal, 663 
purulent, 660 
rheumatic, 673 
tarsi, 701 
Orchitis, acute, 571 

chronic, 563 
Osteosarcoma, 323 
Osseous system, affections of, 285 
Ostitis, 290 
Oxalic diathesis, 518 
Palate, fissure of, 727 

operations for, 727 



Paracentesis abdominis, 512 
Paraphymosis, 588 
Periostitis, 285 
Periostei neuralgia, 289 
Phlebitis, fibrinous, 436 

suppurative, diffuse, 439 
suppurative, limited, 437 
Phlyctenula, 701 
Phosphatic diathesis, 516 
Phymosis, 588 

Plugging posterior nares, 716 
Pneumothorax, 196 
Polypus of nose, 712 

cystomucous, 714 

fibrous, 714 

medullary, 715 

simple, 712 
Prolapsus ani, 653 

complete, 654 
partial, 653 
Prostate, inflammation of, 585 
Purulent ophthalmia, 660 
Pus, 46 

Pustule, malignant, 98 
Rectitis, 649 
Rectum, affections of, 649 

inflammation of, 649 

malignant stricture of, 656 

simple stricture of, 655 
Reef-knot, 610 
Removal of upper jaw, 631 
Resection of joints, 630 

of elbow-joint, 630 
of lower joint, 632 
of shoulder joint, 629 
Resolution, 44 
Restoration of lower lip, 726 

of upper lip, 725 # 
Retention of urine, 594 
Retinitis, 675 
Rhagades, 653 
Rhinoplasties, 717 
Rickets, 315 
Sarcoma, simple, 754 
Sclerotic, affections of, 673 
Sclerotitis, 673 
Sphacelus, 59 

constitutional symptoms of, 59 
local changes in, 60 
Spina ventosa, 322 
Spine, curvatures of, 359 
Strabismus, 695 
Stricture of rectum, 656 

of rectum, simple, 655 

of rectum, malignant, 656 

of urethra, 589 

of ureth»a, permanent, 589 
Suppuration, 45 

in bone, 292 
Synovial membrane, brown degeneration of, 

333 
Synovial membrane, fimbriated, 336 
Synovitis, acute, 324 
chronic, 328 
scrofulous, 331 
Syphilis, 595 

constitutional, 601 

local, 596 

primary, 596 

secondary, 601 

use of mercury in, 606 
Tactus eruditus, 47 
Talipes calcaneus, 385 



784 



Talipes equinus, 382 
valgus, 393 
varus, 388 ' 

Testis, affections of, 561 

cystic sarcoma of, 569 

encephaloid cancer of, 570 

excision, 571 

encysted hydrocele of, 575 

fungous transformation of, 568 

irritable, 565 

neuralgia, 566 

scirrhus, 571 

scrofulous disease of, 567 
Yissues of repair, 52 
Ulceration, 50 
Ulcers, 53 

arrangement of, 53 

gangrenous, 58 
Ulcer, healthy, 53 

indolent, 55 

inflamed, 57 

phagedenic, 58 

sloughing, 58 

phagedaenic, 58 

weak, 54 
Upper jaw, removal of, 631 
Urethra, stricture of, 589 
Urethritis in membranous portion, 585 

prostatic portion, 585 
Urinary calculi, 520 



INDEX. 




t ■■-■ 



n 






Urine, retention of, 594 
Varicose aneurism, 435 

veins, 443 

treatment of, 446 
Varix, 443 

treatment of, 446 
aneurismal, 433 
Veins, diseases of, 436 
Warts, 588 
Wounds, 73 

of abdomen, 507 

by bite of dog, 98 

serpent, 101 

classification of, 73 

of chest, 742 

contused, 85 

dissection, 96 

gunshot, 88 

incised, 76 

lacerated, 84 

modes of healing of, 73 

of neck, 738 

poisoned, 95 

punctured, 86 

from sting of insects, 100 

treatment of, 76 

— for adhesion, 77 
granulation, 82 
Xeroma, 705 
Xerophthalmia, 705 



THE END. 



